GUIDING PRINCIPLES FOR PHYSICIANS RECOMMENDING MOBILE HEALTH APPLICATIONS TO PATIENTS
This document is designed to provide basic information for physicians about how to assess a mobile health application for recommendation to a patient in the management of that patient's health, health care, and health care information.
These guiding principles build on the Canadian Medical Association's (CMA) Physician Guidelines for Online Communication with Patients.1
* Mobile health applications, distinct from regulated medical devices, may be defined as an application on a mobile device that is intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. The functions of these applications may include:
o The ability to store and track information about an individual or group's health or the social determinants thereof;
o Periodic educational information, reminders, or motivational guidance;
o GPS location information to direct or alert patients;
o Standardized checklists or questionnaires.2
* Mobile health applications can enhance health outcomes while mitigating health care costs because of their potential to improve a patient's access to information and care providers.3
* Mobile health applications are most commonly used on a smart phone and/or tablet. Some may also interface with medical devices.
* The use of mobile health applications reflects an emerging trend towards personalized medicine and patient involvement in the management of their health information. By 2016, 142 million health apps will have been downloaded.4 According to some industry estimates, by 2018, 50 percent of the more than 3.4 billion smartphone and tablet users worldwide will have downloaded at least one mobile health application.5
* While mobile health application downloads are increasing, there is little information about usage and adherence by patients. It is believed that many patients cease to use a mobile health application soon after downloading it.
* Distributers of mobile health applications do not currently assess content provided by mobile health applications for accuracy, comprehensiveness, reliability, timeliness, or conformity to clinical practice guidelines.6 However, mobile applications may be subjected to certain standards to ensure critical technical requirements such as accessibility, reachability, adaptability, operational reliability, and universality.
* Increasingly there are independent websites providing reviews of medical apps and checklists for health care professionals. However, the quality criteria used by these sites, potential conflicts of interest, and the scope and number of mobile apps assessed are not always declared by these groups.
To date, randomized controlled trials are not usually employed to assess the effectiveness of mobile health applications. Some believe that the rigorousness of this type of assessment may impede the timeliness of a mobile health application's availability.7
* Some examples of the uses of mobile health applications include tracking fitness activities to supplement a healthy lifestyle; supported self-management of health and health information; post-procedure follow up; viewing of test results; and the virtualization of interaction between patients and providers, such as remote patient monitoring for chronic disease management. Some mobile health applications may be linked to a patient profile or patient portal associated with a professional or recognized association or medical society or health care organization.
* Some mobile health applications may be an extension of an electronic medical records (EMR) platform.
* The objective of recommending a mobile health application to a patient must be to enhance the safety and/or effectiveness of patient care or otherwise for the purpose of health promotion.
* A mobile health application is one approach in health service delivery. Mobile health applications should complement, rather than replace, the relationship between a physician and patient.
* No one mobile health application is appropriate for every patient. Physicians may wish to understand a patient's abilities, comfort level, access to technology, and the context of the application of care before recommending a mobile health application.
* Should a physician recommend a mobile health application to a patient, it is the responsibility of the physician to do so in a way that adheres to legislation and regulation (if existing) and/or professional obligations.
* If the mobile health application will be used to monitor the patient's condition in an ongoing manner, the physician may wish to discuss with the patient what they should watch for and the steps they should take in response to information provided.
* Physicians are encouraged to share information about applications they have found effective with colleagues.
* Physicians who require additional information about the competencies associated with eHealth and the use of health information technologies may wish to consult The Royal College of Physicians and Surgeons of Canada's (RCPSC) framework of medical competencies, CanMEDS.8
* Physicians may wish to enter into and document a consent discussion with their patient, which can include the electronic management of health information or information printed out from electronic management platforms like mobile health applications. This agreement may include a one-time conveyance of information and recommendations to cover the elements common to many mobile health applications, such as the general risk to privacy associated with storing health information on a mobile device.
Characteristics of a safe and effective mobile health application
A mobile health application does not need to have all of the following characteristics to be safe and effective. However, the more of the following characteristics a mobile health application has, the likelier it will be appropriate for recommendation to a patient:
1. Endorsement by a professional or recognized association or medical society or health care organization
As recommended by the Canadian Medical Protective Association (CMPA), it is best to select mobile health applications that have been created or endorsed by a professional or recognized association or medical society.9 Some health care organizations, such as hospitals, may also develop or endorse applications for use in their clinical environments. There may also be mobile health applications associated with an EMR platform used by an organization or practice. Finally, some mobile health applications may have been subject to a peer review process distinct from endorsement by an association or organization.
There are a number of usability factors than can complicate the use of mobile applications, including interface and design deficiencies, technological restrictions, and device and infrastructure malfunction.
Many developers will release periodic updates and software patches to enhance the stability and usability of their applications. Therefore, it would be prudent for the physician recommending the mobile health application to also recommend to the patient that they determine if the application has been updated within the last year.
Physicians considering recommending a mobile health application to a patient may wish to ask about the patient's level of comfort with mobile health technologies, their degree of computer literacy, whether or not the patient owns a mobile device capable of running the application, and whether or not the patient is able to bear potential one-time or ongoing costs associated with use of the application.
Physicians may consider testing the application themselves beforehand to understand whether its functionality and interface make it easy to use.
3. Reliability of information
Physicians considering recommending a mobile health application may wish to understand how the patient intends to use the information, and/or review the information with the patient to understand whether it is current and appropriate.
Information presented by the mobile health application should be appropriately referenced and time-stamped with the last update by the application developer.
4. Privacy and security
In 2014, the Officer of the Information and Privacy Commissioner of Alberta assessed approximately 1200 mobile applications and found nearly one-third of them required access to personal information beyond what should be required relative to their functionality and purpose, and that basic privacy information was not always made available.10
Physicians entering into and documenting a consent discussion with their patients may wish to include the electronic management of health information in the scope of these discussions, and make a notation of the discussion in the patient's health record.
Some mobile health applications may feature additional levels of authentication for use, such as an additional password or encryption protocols. If all other factors between applications are equal, physicians may wish to recommend that patients use mobile health applications adhering to this higher standard of security.
5. Avoids conflict-of-interest
Physicians may wish to recommend that patients learn more about the company or organization responsible for the development of the application and their mandate. There is a risk of secondary gains by mobile health application developers and providers where information about patients and/or usage is gathered and sold to third parties.
A standardized conflict of interest statement may be made available through the mobile health application or on the developer's website. If so, physicians may wish to refer the patient to this resource.
Physicians who develop mobile applications for commercial gain or have a stake in those who develop applications for commercial gain may risk a complaint being made to the College on the basis that the physician engaged in unprofessional conduct if they recommend mobile health applications to their patients in the course of patient care.
6. Does not contribute to fragmentation of health information
Some mobile health applications may link directly to an EMR, patient portal, or government data repository. These data resources may be standardized, linked, and cross-referenced.
However, health information entered into an application may also be stored on a mobile device and/or the patient's home computer, or developers of mobile health applications may store information collected by their application separately. While there may be short-term benefits to using a particular mobile health application, the range of applications and developers may contribute to the overall fragmentation of health information.
If all other factors between applications are considered equal, physicians may wish to recommend mobile health applications which contribute to robust existing data repositories, especially an existing EMR.
7. Demonstrates its impact on patient health outcomes
While not all mobile health applications will have an appropriate scale of use and not all developers will have the capacity to collect and analyze data, physicians may wish to recommend mobile health applications that have undergone validation testing to demonstrate impact of use on patient health outcomes. If mobile health applications are claiming a direct therapeutic impact on patient populations, physicians may wish to recommend that their patients seek out or request resources to validate this claim.
1 Canadian Medical Association. Physician guidelines for online communication with patients. Ottawa: The Association; 2005. Available: http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD05-03.pdf?_ga=1.32127742.1313872127.1393248073
2 US Food and Drug Administration, Center for Devices and Radiological Health, Center for Biologics Evaluation and Research. Mobile medical applications: guidance for industry and Food and Drug Administration staff. Rockville (MD): The Administration; 2015. Available:
3 Canada Health Infoway. Mobile health computing between clinicians and patients. White paper. Toronto: The Infoway; 2014 Apr. Available: www.infoway-inforoute.ca/index.php/resources/video-gallery/doc_download/2081-mobile-health-computing-between-clinicians-and-patients-white-paper-full-report
4 iHealthBeat. 44M mobile health apps will be downloaded in 2012, report predicts. Available: www.ihealthbeat.org/articles/2011/12/1/44m-mobile-health-apps-will-be-downloaded-in-2012-report-predicts
5 Jahns R-G. 500m people will be using healthcare mobile applications in 2015. Research2guidance. Available: www.research2guidance.com/500m-people-will -be-using-healthcare-mobile-applications-in-2015/
6 Lyver, M. Standards: a call to action. Future Practice. 2013 Nov. Available: www.cma.ca/Assets/assets-library/document/en/about-us/FP-November2013-e.pdf
7 Rich P. Medical apps: current status. Future Practice 2013 Nov. Available: www.cma.ca/Assets/assets-library/document/en/about-us/FP-November2013-e.pdf
8 Royal College of Physicians and Surgeons of Canada. The CanMEDS 2015 eHealth Expert Working Group report. Ottawa: The College; 2014. Available: www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/ehealth_ewg_report_e.pdf
9 Canadian Medical Protective Association. Managing information to delivery safer care. Ottawa: The Association; 2013. Available: https://oplfrpd5.cmpa-acpm.ca/en/duties-and-responsibilities/-/asset_publisher/bFaUiyQG069N/content/managing-information-to-deliver-safer-care
10 Office of the Information and Privacy Commissioner of Alberta. Global privacy sweep rasies concerns about mobile apps [news release]. Available: www.oipc.ab.ca/downloads/documentloader.ashx?id=3482
The Canadian Medical Association (CMA) supports the promotion of healthy lifestyles in order to improve individual health and well-being and the overall health status of the population. Healthy lifestyles refer to patterns of individual practices and personal behavioural choices that are associated with optimal health. Two of the most important behaviours to create or maintain optimum health are healthy eating and physical activity.
For many Canadians, their diet and physical activity levels can have a negative rather than positive impact on their overall health. There is a particular concern for children and youth who are growing up in increasingly obesogenic environments that reinforce practices that work against a healthy lifestyle.1 Childhood obesity research tells us that overweight and obese children are more likely to stay the same into adulthood.2 To reverse this trend, determined action is required for children and youth to learn and acquire healthy behaviours that they will maintain throughout their life. Healthy lifestyles are central to successful aging and improving the likelihood of recovery after poor health.3
This policy paper discusses the importance of physical activity and healthy eating, and the role that individuals and families, schools, workplaces, communities, the food industry and all levels of governments can play in promoting healthy lifestyles. We know that collaborative action is required to make it easier for Canadians to incorporate healthy eating and physical activity into their daily lives - to make the healthy choice the easy choice.
What are the health impacts of unhealthy diets and physical inactivity
Diet is the leading risk factor for death, disability and life-years lost; being estimated to cause over 65,000 deaths and 864,000 life years lost in Canada in 2010.4
Unhealthy diet has been consistently linked with cardiovascular diseases (heart disease, stroke, hypertension, diabetes, dyslipidemia) and some cancers,5 which constitutes the majority of the disease burden in Canada. An estimated 80% of hypertension, which affects over 7 million Canadians, is directly or indirectly attributed to unhealthy diet.6
An estimated 60% of Canadian adults and close to one-third of children are overweight or obese, largely caused by unhealthy diets.7 Overweight and obesity (and the lifestyle choices associated with them) are contributors to more than 18 chronic conditions.8 This includes diabetes, cardiovascular disease, hypertension and liver disease, as well as breast, colon and prostate cancer.
Obesity is a public health issue not unique to Canada as the rates are increasing worldwide. Obesity is generally attributed to the fact that, as a society, we are increasing our calorie intake while at the same time burning less energy in physical activity. While it is difficult to determine how many deaths are directly attributable to obesity, we know that obesity often co-exists with other risk factors such as the lack of physical activity.
Exercise is one of the top modifiable risk factor for chronic disease.9 Regular physical activity is associated with a reduced risk of cardiovascular disease, some types of cancer, diabetes, obesity, hypertension, bone and joint diseases, and depression.10 The risk for many of these conditions is reduced by 20 - 40% in adults with the highest levels of physical activity compared to those with the lowest levels of physical activity. Recent research has shown that a sedentary lifestyle is associated with higher risk for chronic conditions such as obesity, diabetes and cancer independent of physical activity levels.11
According to the most recent Canadian Health Measures Study physical activity levels for children and youth are low with 6 out of 10 waking hours devoted to sedentary pursuits. Obesity is rising and physical fitness is declining.12
Canadians who do not achieve adequate levels of physical activity or eat unhealthy foods are vulnerable to preventable chronic diseases, premature death, and contribute to high health care costs. For instance, in 1999, $2.1 billion or 2.5% of the total direct health care costs were attributable to physical inactivity.13
To understand why the rates of obesity and overweight are rising, it may be helpful to look at what we already know about healthy eating and physical activity.
What we know about healthy eating
While modern science has allowed us to expand our knowledge of the impact of nutrients and food on human health we continue to be beset with illness and disease caused by the foods we consume. Having the right amount and type of food recommended in Canada's Food Guide is a first step towards healthy eating. But Canadians self-reported dietary intakes do not meet national dietary recommendations despite high reliance on public education concerning healthy eating and healthy diets. Children and adults are under-consuming the recommended servings of vegetables and fruits, an established proxy for healthy eating habits, and exceeding daily recommended intakes of sodium.14,15
As the links between nutrition and disease, and the impact on the health of our society are revealed it is more important than ever to understand what influences healthy eating behaviours. Food choices are structured by a variety of individual determinants of behaviour, ranging from one's physiological state, food preferences, nutritional knowledge, perceptions of healthy eating and psychological factors.
Many processed foods have become popular due to their accessibility and 'convenience factor', but these features have changed the way food and in particular these products are consumed compared to unprocessed foods: increased 'grazing', eating alone or eating while carrying out other activities such as work or driving. In addition, many calories consumed come in liquid form.16
Growth in the production and consumption of ultra-processed foods has increased drastically in the last decades in both higher and lower-income countries.17 A number of studies have shown that because less healthy foods are cheaper than healthier food, individuals from lower socioeconomic classes tend to be more dependent on unhealthy foods for nourishment.18
Other determinants for healthy eating include a wide range of contextual factors, such as the interpersonal environment created by family and peers, the physical environment, which determines food availability and accessibility, the economic environment, in which food is a commodity to be marketed for profit, and the social environment. Within the social environment, social status (income, education and gender) and cultural milieu are determinants of healthy eating that may be working "invisibly" to structure food choice.19
What we know about physical activity
Canada's Physical Activity Guidelines recommend that children and youth aged 5 to 17 get at least 60 minutes of moderate-to-vigorous physical activity (MVPA) per day; and adults get 150 minutes of physical activity per week.20 In fact, about 94% of Canadian children and youth do not meet minimum physical activity guidelines.21 Furthermore, about 85% of Canadian adults do not meet the minimum guidelines. Physical activity includes but is not limited to sports and recreation. Using active transportation to get to work as well as being active at work is an alternative form of MVPA and can also lead to improved health.
For most Canadians, the average day is spent on passive activities such as TV viewing, computer and game-console use, workplace sitting, and time spent in automobiles. Moreover, the sprawling suburban communities, in which many live, do not encourage physical activity.
Emerging research suggests that prolonged sitting time is associated with an increased health risk.22 These findings mean that one can meet the minimum physical activity guidelines and still not engage in a healthy lifestyle. Spending a few hours a week at the gym or otherwise engaged in moderate or vigorous activity doesn't seem to significantly offset the risk. Hence too much sitting is a risk distinct from too little exercise.
While further research is required to identify which methods of exercise promotions work best for individuals,23 it is clear that supportive environments and infrastructures are essential for Canadians to make physical activity part of their daily lives. CMA's policies about the Built Environment and Active Transportation support the role of the environment on our physical activity patterns.
How we can promote physical activity and healthy eating
A sedentary lifestyle is a cue for physician advice.24 Physical activity is a vital sign that may require as much attention as other traditional vital signs25 - weight, blood pressure, or smoking history. Physicians are eager to initiate these conversations, especially with patients living with chronic diseases. A message must be repeated many times in order to effect a change in lifestyle. Physicians can reiterate the medical importance of physical activity and healthy eating by reinforcing this message during each office visit, and writing the recommendation on a prescription pad.26 For instance, in British Columbia, physicians are prescribing exercise on specially-designed pads, distributing free pedometers, and hosting free walking events for their patients and the public. In the Edmonton area, Primary Care Networks are prescribing free access passes or a free month of access at local municipal recreation facilities. And in Nova Scotia, physicians have been running a free provincial running program for over 10 years that benefits thousands of kids in elementary school.
Nonetheless these clinical interventions alone cannot shape healthier food consumption patterns and lifestyle choices. An obvious starting point to develop a comprehensive policy is to understand the interplay between individual and environmental determinants that influence our behaviours. In this regard, CMA has developed policies on Active Transportation and the Built Environment and Health which recognize the role of neighborhood design and alternative modes for transportation for an active lifestyle. This approach is also at the heart of the Integrated Pan-Canadian Healthy Living Strategy (PCHLS)27, approved in 2005 by all levels of government. CMA commends the efforts put in the PCHLS to prioritize healthy eating and physical activity.
What we recommend
CMA looks forward to working with others in making options for physical activity and healthy eating more available and accessible to all Canadians. The following recommendations highlight the potential contributions of the following sectors: health professionals, all levels of government, communities, workplaces, schools, the food industry and individuals and families.
CMA encourages physicians to promote healthy eating and physical activity inside and outside their office.
Physicians are lifestyle change agents and remain the preferred source of information about health for many people. Physicians, who are committed to physical activity, are role models whose advice on healthy living is more likely to be adopted.28 CMA encourages physicians to address any work-imposed limitations - such as the lack of time, motivation, or tiredness - that could also influence their own exercise and eating habits.
In clinical practice, physicians can help patients start or maintain a healthy lifestyle by:
* assessing nutrition and physical activity as part of routine assessments;
* determining the factors that influence individual patient's nutrition and physical activity levels;
* assessing patient's readiness to change and tailoring interventions and support to their current situation;
* providing an exercise prescription to encourage physical activity to maintain or improve health status, and
* working in inter-professional teams to provide patient education with other health care providers such as dieticians.
Medical students and residents, while reporting a high level of importance for exercise prescription concede a low level of expertise in this area upon graduation.29,30,31 As knowledge develops, physicians and other health professionals should be kept updated and encouraged to incorporate the most effective interventions into their practices. The CMA encourages the development of continuing medical education courses on issues related to physical activity and healthy eating.
Within the healthy living approach, there are multiple opportunities to extend the role of physicians into the community as observed in Nova Scotia, British Columbia and Edmonton area. Physicians can establish strong community norms for a healthy lifestyle by:
* establishing and reinforcing healthy food policies in hospital cafeterias or at health-related meetings and conferences
* using, facilitating and advocating for the use of active transportation in their communities
* working within the community to ensure that recreation centres and other facilities are available and patients can be referred to the services most appropriate to their needs
Federal, Provincial, and Territorial Governments
CMA calls on federal, provincial, territorial and municipal governments to commit to a long-term, well-funded Canada-wide strategy for healthy living beyond 2015.
In 2005, Canada's federal, provincial, and territorial governments endorsed a 10-year Healthy Living Strategy Framework, whose initial priorities included the promotion of healthy eating and physical activity. The national strategy addressed information and support for Canadians to help them make healthy choices; support for physicians and other health professionals in counselling patients on healthy weight and in treating existing obesity; community infrastructures that make healthy living easier; and public policies that encourage healthy eating and physical activity. The federal and provincial / territorial governments have undertaken a number of activities in the intervening years to promote physical activity and healthy eating but much remains to be done.
CMA believes that all levels of governments have a continuous obligation to provide public guidance on healthy eating and to promulgate policies, standards, regulations and legislations that support the availability and accessibility of healthy and affordable food and beverage choices.
CMA calls on governments to improve access to nutritious food at affordable prices for all Canadians.
The price of milk, fresh produce and other healthy foods can vary greatly across Canada. In many remote areas, they are often more expensive than processed, nutrition-poor foods because of high transportation costs. Governments should implement effective programs to offset the impact of transportation costs on food prices in northern and remote communities. Even in urban areas, nutritious food may be unaffordable for people on low incomes. School meal programs, social assistance rates that take into account the cost of purchasing healthy food, access to urban farmers' markets can help to ensure that all Canadians have access to healthy foods at a reasonable price.
CMA calls on governments to ban marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger.
The typical Canadian child may be exposed to as many as 40,000 advertisements for food a year.32 This does not include point-of-sale promotions, such as displays of candy bars at convenience-store counters. CMA's policy on marketing of unhealthy foods and beverages to children and youth calls for a ban on marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger.
CMA calls on governments to set rigorous standards for front of package food labeling and for the advertising of health claims for food.
Brand-specific advertising is a less than optimal way to provide health information to consumers, who should be encouraged to seek out objective information sources for answers to their questions about physical activity and healthy eating. To improve the quality of information received through commercial channels, the CMA recommends that health claims made for foods be strictly regulated to ensure that they are based on the best available scientific evidence and that they are accurately communicated to consumers. Food advertisements should be pre-cleared before airing in the media, and the provisions against deceptive advertising in the Food and Drug Act should be strengthened.
CMA recommends that governments at all levels invest in evidence-based research on healthy eating and physical activity and share the results of this research with all Canadians.
CMA encourages all levels of governments to continue to fund and support research for healthy lifestyles. There is a clear need to invest in research to strengthen the evidence base about physical activity and healthy eating, particularly on:
best measures for assessing overweight and obesity;
the effectiveness of weight management and treatment programs; and
the effect of policy interventions on healthy eating and physical activity on rates of obesity and obesity-related disease.
CMA encourages governments to continue to work with the food industry to improve the food environment in Canada.
The partnership and collaboration of food manufacturers is needed to help Canadians make healthier food choices. The food industry can work with governments to:
reduce the salt, sugar, saturated fat, trans fat and calorie content of processed foods and pre-prepared meals;
provide information about the calorie and nutrition content on restaurant menus;
restrict advertising and in-store promotion of high-sugar, high-salt, high-fat foods, particularly those aimed at children;
provide user-friendly consumer information about their products, including and accurate health and advertising claims;
improve the nutrition fact table to make it more user friendly and increase the amount of information for example, by identifying the amount of free sugars.
CMA calls on municipal governments to create environments that encourage healthy and active living and on federal, provincial and territorial governments to support them in this endeavour.
Communities have an important role to play to promote healthy behaviours for children, youth, and adults. They shape how many Canadians decide to live, work and play in their daily life. Through mixed-use land planning and building design, communities can create walking-friendly environments, and reduce the time people spend in cars. To achieve this, communities should consider:
developing and maintaining a community-wide network of walking and cycling paths;
zoning communities in such a way that amenities are within walking distance of homes; and
revising building codes to make stairs accessible, pleasant and safe, so that people have an alternative to taking the elevator.
Canadians are considerably more physically active in the summer than in the winter and this could have an impact on obesity trends.33 Communities could improve pathways to healthy lifestyles year-round by improving access to indoor sport and recreation facilities, especially during winter. Where possible, communities should consider partnering with schools to share the use of gymnasiums, playgrounds, fields, courts, and tracks with the public after school hours and on weekends. In doing so, communities are ensuring the best use of time and resources, but also sharing liability for the development, operation, and maintenance of the facilities.
Community food security can happen if local residents have equal access to safe, affordable and nutritious food. Communities have a role to play in advocating for healthier food options in schools and workplaces, encouraging community kitchens to teach cooking skills, and supporting local agriculture and farmers markets. This, in turn, would encourage individuals to eat more healthy foods.
CMA encourages employers to actively promote the health of their employees by providing opportunities for physical activity, and healthy food choices in cafeterias.
Prolonged, unbroken time spent sitting in front of a screen is very common in the workplace. In addition, four out of five commuters sit daily in their private vehicles to go to work.34 As Canadians spend most of their adult life at work, it is important to reduce workplace sitting. CMA encourages employers, especially in sedentary occupational groups, to increase opportunities for physical activity. For example, employers can promote healthy behaviours by:
Building on-site fitness facilities or entering into agreements with off-site fitness centres to provide programs for their employees
Providing showers, bike racks and other amenities for employees for those who want to commute to work on foot or by bike.
Healthier food options in cafeteria and vending machines can promote and encourage healthy eating by employees.
Schools, where children spend most of their time outside of home, present an excellent opportunity to instil healthy behaviours at an early age. They could, for example, provide comprehensive nutrition education, serve nutritious food in their cafeterias and promote physical activity by providing formal instruction and informal recreation time. Schools can provide the most effective and efficient way to reach not only the children themselves, but their parents, teachers, and other community members.35
CMA encourages school boards to provide at least 60 minutes of active daily physical education for all primary and secondary grades.
Only 26% of Canadian schools reported that they had implemented daily physical education classes for their students.36 There is some evidence that school-based physical activity can increase physical activity levels and reduce time spent watching television at home. 37 For instance, schools can promote physical activity through unstructured out-of-home play, structured sports, or active transportation (e.g. walking to school). Children who are physically active and spend less time watching television after school are less likely to become overweight before age 12.38
CMA recommends that schools provide access to attractive, affordable, healthy food choices, provide nutrition education, and initiate programs aimed at encouraging healthy food consumption and skills to prepare meals from scratch.
CMA calls for restrictions on the sale of high-calorie, high fats, sugars or salts foods/drinks in recreational facilities frequented by young people.
Fast food restaurants and convenience stores can be an important influence on children's eating habits and food choices.39 Children attending schools within a short distance of fast food restaurants eat fewer fruits and vegetable servings, and drink more soft drinks than others who did not have similar establishments within proximity.40 To encourage effective school-based nutrition interventions, it is therefore important to educate students about the nutrition value of foods, healthy food choices, and provide healthy canteens or cafeterias.
Individuals and families
CMA recommends that all Canadians work toward achieving and maintaining health by:
educating themselves about their dietary needs and about the caloric and nutrition content of foods; and
engaging in physical activity, with the goal of at least 60 minutes of moderate activity per day for children and youth, and 150 minutes per week for adults.
Ultimately, healthy eating and physical activity require that individuals take action to make healthy choices in their lives. To inform these choices, Canadians should be supported with appropriate resource materials with consistent information about healthy eating and physical activity. For instance, many young children do not choose what they consume; their parents buy and prepare the food for them. Research suggests that mothers and children appear to have divergent attitudes towards food and mealtimes.41 In this regard, it is important for parents to be well-informed and able to explain the tangible benefits of foods and their nutritional components to their children before they reach adulthood.
What we conclude
Healthy behaviours are easier to maintain through life if acquired in childhood and encouraged by the family. Therefore Canadian families should be supported in efforts to ensure that both children and adults eat nutritiously and exercise daily. We believe there is a role for everyone in promoting healthy behaviours - including health professionals, individuals, families, schools, workplaces, communities, the food industry and all levels of governments.
Popular approaches seek to provide individuals with information and options about healthy lifestyles choices. However, individual choice is not sufficient to ensure healthy behaviours.
Many barriers to the adoption of healthy behaviours and lifestyle choices can be met through a targeted population health approach, and evidence-based policy and regulatory controls. A comprehensive change in culture and mindset, political endorsement and multifaceted strategies are needed to promote and facilitate change to improve the dietary practices and physical activity levels of Canadians.
Summary of Recommendations
1. The Canadian Medical Association encourages physicians to promote healthy eating and physical activity inside and outside their office.
2. The Canadian Medical Association calls on federal, provincial, territorial and municipal governments to commit to a long-term, well-funded Canada-wide strategy for healthy living beyond 2015.
3. The Canadian Medical Association calls on governments to improve access to nutritious food at affordable prices for all Canadians.
4. The Canadian Medical Association calls on governments to ban marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger.
5. The Canadian Medical Association calls on governments to set rigorous standards for front of package food labeling and for the advertising of health claims for food.
6. The Canadian Medical Association recommends that governments at all levels invest in evidence-based research on healthy eating and physical activity and share the results of this research with all Canadians.
7. The Canadian Medical Association encourages governments to continue to work with the food industry to improve the food environment in Canada.
8. The Canadian Medical Association calls on municipal governments to create environments that encourage healthy and active living and on federal, provincial and territorial governments to support them in this endeavour.
9. The Canadian Medical Association encourages employers to actively promote the health of their employees by providing opportunities for physical activity, and healthy food choices in cafeterias.
10. The Canadian Medical Association encourages school boards to provide at least 60 minutes of active daily physical education for all primary and secondary grades.
11. The Canadian Medical Association recommends that schools provide access to attractive, affordable, healthy food choices, provide nutrition education, and initiate programs aimed at encouraging healthy food consumption and skills to prepare meals from scratch.
12. The Canadian Medical Association calls for restrictions on the sale of high-calorie, high fats, sugars or salts foods/drinks in recreational facilities frequented by young people.
13. The Canadian Medical Association recommends that all Canadians work toward achieving and maintaining health by:
* educating themselves about their dietary needs and about the caloric and nutrition content of foods; and
* engaging in physical activity, with the goal of at least 60 minutes of moderate activity per day for children and youth, and 150 minutes per week for adults.
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2 Waters E, de Silva-Sanigorski A, Hall BJ, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2011;(12): CD001871.
3 Shields M, Martel L. (2006). Healthy living among seniors. Ottawa: Statistics Canada; 2005. Available: www5.statcan.gc.ca/bsolc/olc-cel/olc-cel?catno=82-003-S20050009086&lang=eng (accessed 2014 Jan 20).
4 Institute for Health Metrics and Evaluation. Global burden of disease arrow diagram. Seattle (WA): The Institute; 2013. Available: www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram (accessed 2010 Mar 15)
5Committee on Public Health Priorities to Reduce and Control Hypertension in the U.S. Population, Institute of Medicine of the National Academies. A population-based policy and systems change approach to prevent and control hypertension. Report, v-173. Washington (DC): National Academies Press; 2010.
6 Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis. Lancet 2011;377(9775):1438-47.
7 Roberts KC, Shields M, de Groh M, et al. Overweight and obesity in children and adolescents: results from the 2009 to 2011 Canadian Health Measures Survey. Health Rep. 2012;23(3):37-41.
8 Canadian Institute for Health Information, Public Health Agency of Canada. Obesity in Canada. Ottawa: The Agency; 2011. Available: www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/index-eng.php (accessed 2014 Jan 20).
9 Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease study 2010. Lancet. 2012;380:2224-60.
10Colley, R, Garriguet D, Janssen I, et al. Physical activity of Canadian adults: accelerometer results from the 2007 to 2009 Canadian Health Measures Study. Statistics Canada Cat. No. 82-003 XPE. Health Rep. 2011 Mar;22(1).
11 Statistics Canada. Directly measured physical activity of Canadian adults, 2007-2011. Health fact sheets. Ottawa: Statistics Canada; 2013.
12 Colley R, Garriguet D, Janssen I, et al. Physical activity of Canadian children and youth: accelerometer results from the 2007 to 2009 Canadian Health Measures Study. Statistics Canada Cat. No. 82-003 XPE. Health Rep. 2011 Mar;22(1).
13 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada CMAJ. 2000;163(11):1435-40.
14 Statistics Canada. Fruit and vegetable consumption. Health fact sheets. Statistics Canada Cat. No. 82-625-XWE. Ottawa: Statistics Canada; 2012. Available: www.statcan.gc.ca/pub/82-625-x/2013001/article/11837-eng.htm (accessed 2013 Nov 8).
15 Garriguet D. Canadians' eating habits. Statistics Canada Cat. No. 82-003. Health Rep. 2007;18(2):17-32. Available: www.statcan.gc.ca/pub/82-003-x/2006004/article/habit/9609-eng.pdf (accessed 2013 Jul 10).
16 Monteiro CA. Nutrition and health. The issue is not food, nor nutrients, so much as processing. Public Health Nutr. 2009;12(5):729-31. DOI:10.1017/S1368980009005291.
17 Monteiro CA, Levy RB. A new classification of foods based on the extent and purpose of their processing. Uma nova classifi cação de alimentos baseada na extensão e propósito do seu processamento. Cad Saude Publica. 2010;26(11):2039-49.
18 World Health Organization. Obesity the "new norm": day 1 of nutrition and NCDs conference. 2013. Available: www.euro.who.int/en/health-topics/health-policy/pages/news/news/2013/07/obesity-the-new-norm-day-1-of-nutrition-and-ncds-conference
19 Raine KD. Determinants of healthy eating in Canada: an overview and synthesis. Can J Public Health. 2005;96(Suppl 3):S8-14, s18-15.
20 Canadian Society for Exercise Physiology. Canadian physical activity guidelines. Ottawa: The Society; 2011. Available: www.csep.ca/guidelines (accessed 2014 Jan 20).
21 Statistics Canada. Canadian health measures survey: directly measured physical activity of Canadians, 2007 to 2011. The Daily. Ottawa: Statistics Canada; 2013 May 30. Available: www.statcan.gc.ca/daily-quotidien/130530/dq130530d-eng.pdf (accessed 2014 Jan 20).
22 Owen N, Healy GN, Matthews CE, et al. Too much sitting: the population health science of sedentary behavior. Exerc Sport Sci Rev. 2010;38(3):105-13.
23 Foster C, Hillsdon M, Thorogood M, Kaur A, Wedatilake T. Interventions for promoting physical activity. Cochrane Database Syst Rev. 2013 (1). Review.
24 Glasgow RE, Eakin EG, Fisher EB, et al. Physician advice and support for physical activity results from a national survey. Am J Prev Med. 2001;21(3):189-96.
25 Salis R. Developing healthcare systems to support exercise: exercise as the fifth vital signs. Br J Sports Med. 2011;45(6):473-4.
26 Andersen RE, Blair SN, Cheskin LJ, et al. Encouraging patients to become more physically active: the physician's role. Ann Intern Med. 1997;127(5):395-400.
27 Public Health Agency of Canada. Overview of the Pan-Canadian Healthy Living Strategy. 2010. Available: www.phac-aspc.gc.ca/hp-ps/hl-mvs/ipchls-spimmvs-eng.php (accessed 2014 Jan 20).
28 Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009;43(2):89-92.
29 Rogers LQ, Gutin B, Humphries MC, et al. Evaluation of internal medicine residents as exercise role models and associations with self-reported counseling behavior, confidence, and perceived Success. Teach Learn Med. 2006;18(3):215-21.
30 Connaughton AV, Weiler RM, Connaughton DP. (May-June 2001). Graduating medical students' exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Healthy People 2010. Public Health Rep. 2001;116:226-34.
31 Vallance JK, Wylie M, MacDonald R. Medical students' self-perceived competence and prescription of patient-centered physical activity. Prev Med. 2009;48(2):164-6. DOI: 10.1016/j.ypmed.2008.12.006
32 The Kaiser Family Foundation. The role of media in childhood obesity. Menlo Park (CA): The Foundation; 2004 Feb. Available: http://kaiserfamilyfoundation.files.wordpress.com/2013/01/the-role-of-media-in-childhood-obesity.pdf (accessed 2014 Mar 19).
33 Merchant AT, Dehghan M, Akhtar-Danesh N. Seasonal variation in leisure-time physical activity among Canadians Can J Public Health. 2007;98(3):203-8.
34 Statistics Canada. Commuting to work. National Household Survey. 2011. Available: https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-012-x/99-012-x2011003_1-eng.cfm (accessed 2014 Jan 20).
35 Perez-Rodrigo C. School-based nutrition education: lessons learned and new perspectives. Public Health Nutr. 2001;4(1A):131-9.
36 Canadian Fitness and Lifestyle Research Institute. Policies related to physical activities. 2011 opportunities for physical activity at school survey. 2012 Aug 14. Available: http://www.cflri.ca/sites/default/files/node/1054/files/Schools%202011%20Bulletin%2012%20-%20Policy%20EN.pdf
(accessed 2013 Sep 15).
37 Dobbins M, Husson H, DeCorby K, et al. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database Syst Rev. 2013;2:CD007651.
38 O'Brien M, Nader PR, Houts RM, et al. The ecology of childhood overweight: a 12-year longitudinal analysis. Int J Obes (Lond). 2007;31(9):1469-78.
39 Howard PH, Fitzpatrick M, Fulfrost B Proximity of food retailers to schools and rates of overweight ninth grade students: an ecological study in California. BMC Public Health. 2011;11(68).
40 Davis B, Carpenter C. Proximity of fast-food restaurants to schools and adolescent obesity. Am J Public Health. 2009;99(3):505-10.
41 Le Bigot Macaux A. Eat to live or live to eat? Do parents and children agree? Public Health Nutr. 2001;4(1A):141-6.
IMPROVING EFFICIENCY IN THE CANADIAN HEALTH CARE SYSTEM
Achieving value in health care systems is an important objective for all nations.1 Health care systems in Canada and elsewhere are examining ways to address inefficiencies to make the system more cost-effective and sustainable while improving the quality, continuity, and comprehensiveness of care. This policy statement puts forth recommendations for system sustainability and improving quality of care. All system stakeholders including providers, funders and patients bear responsibility to ensure the health care system is as efficient as possible. Physician input is a necessary condition for meaningful system improvement and innovation.
Health care systems in Canada and elsewhere are examining ways to address inefficiencies to make the system more cost-effective and sustainable while improving the quality, continuity, and comprehensiveness of care. The concept of efficiency in health care has two applications. The most common is technical efficiency, which is defined as producing maximum output for a given level of inputs, or minimizing input for a given level of output.2 The difference between actual output and the maximum achievable output may be attributed to inefficiency within the system.
The second is called allocative efficiency, which refers to optimizing resource allocation to produce maximum outputs that fulfill societal demands. Canadian research suggests that increasing technical and allocative efficiency rather than increasing spending could solve some of the current challenges regarding health care quality and sustainability. Based on a macro system-level approach to estimating efficiency among its member countries, the Organization for Economic Cooperation and Development (OECD) has estimated that all of its member countries could achieve better value from their health care spending-Canada could save 2.5% of Gross Domestic Product in public spending by 2017 if it were to become as efficient as the most efficient OECD countries.3
2. Health care inefficiencies
The various inefficiencies in the Canadian health care system may be categorized and visualized using the conceptual framework developed by Bentley et al in 2008 for the U.S. health care system 4 (see Figure 1). In Canada, no such framework exists.
The framework of Bentley et al contains three main categories of inefficiencies - clinical, operational, and administrative. Clinical inefficiencies relate to practice variation challenges including, the provision of inappropriate care. Operational inefficiencies include duplication of health care services, inefficient processes, overly expensive inputs, and errors in data collection and processing. Administrative inefficiencies may be generally thought of as excess transaction costs associated with claims payment and excess costs of administration and management over and above what is required to deliver front-line health care.
Figure 1. Typology of health care inefficiencies
Source: Adapted from Bentley et al, 2008.
2.1 Clinical Inefficiencies
Clinical waste and inefficiencies refer to services that provide marginal or no health benefit compared with less costly alternatives. This may include practice variation and the provision of inappropriate and cost-ineffective care, or the underuse of more appropriate care. There is overlap between clinical inefficiencies (e.g., providing the wrong service) with operational inefficiencies (the inefficient production of services).
The chief contributor to clinical inefficiencies or waste in the health care field is practice variation-the reduction of unwarranted care variation is the foundation of the quality movement. John Wennberg and colleagues have pioneered the main body of work in this area through their studies on small area variation in care delivery.5 Over the last quarter century, technical studies on clinical practice guidelines (CPGs) have been developed in increasing numbers to address issues of appropriateness of care and care variation.
CPGs are defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances".6 CPGs should contribute to better health, enhance the quality of care by reducing practice variation, and contribute to better value and lower costs by encouraging more appropriate use of resources by care providers.7 Although there has been no systematic approach in Canada to developing and disseminating CPGs, or to ensuring the quality of the CPGs produced, various organizations have developed initiatives to tackle this issue.8
Since the early 1990s, the Canadian Medical Association (CMA) has developed and maintained a CPG Infobase, which contains roughly 1,200 guidelines.9 The uptake of CPGs is a crucial component and insufficient resources are applied to necessary clinical practice change processes. Moreover, CPGs should be distillable to actionable points-of-care recommendations suited to the intended end user (e.g., family physicians).
In January 2012, the Council of the Federation (CoF) established the Health Care Innovation Working Group, which comprises all provincial and territorial health ministers, to determine practical and innovative ways to increase the value and effectiveness of care.10 The group's CPG recommendations focused on cardiovascular disease and diabetes - two of the most prevalent and highest-costing chronic diseases in Canada (see Appendix A for list of CPGs). In accordance with the CoF, the CMA recommends:
1. Developing chronic disease management and other supportive strategies for vulnerable patients at risk of frequent readmission to the acute care system.
2. Integrating clinical practice guidelines with electronic medical records.
3. Implementing a pan-Canadian clinical practice guidelines strategy.
4. Using evidence-informed clinical practice guidelines to evaluate patient outcomes, appropriateness, and cost-effectiveness.
5. Developing deployment strategies to ensure maximum use of clinical practice guidelines by physicians.
Clinical practice guidelines need regular updating as new evidence emerges. Therefore, a Pan-Canadian strategy should include a system of regular review and updating using development methods that would exclude the possibility of industry bias. Canada's physicians are taking a leading role on this matter through such initiatives as Choosing Wisely Canada (see below).
There is an increasing trend in health care utilization in areas such as medical procedures, drugs, and physician services.11 Questions remain about whether or not people are receiving care that is appropriate and based on the best available scientific information.12 Inappropriate care, such as the hospitalization of patients who need community-based services or prescribing antibiotics for upper respiratory infections that are likely viral in origin, is another source of clinical inefficiency, using scarce resources for marginal or no health benefit.
The CMA recently defined appropriate care as the right care, provided by the right provider, to the right patient, in the right venue, at the right time:
* "right care" is based on evidence for effectiveness and efficacy in the clinical literature, and not only implies appropriateness of use, but inappropriateness of failure to use;
* "right provider" is based on ensuring the provider's scope of practice adequately meets but does not far exceed the skills and knowledge to deliver the care;
* "right patient" acknowledges that care choices must be matched to individual patient characteristics and preferences;
* "right venue" emphasizes that some settings are better suited in terms of safety and efficiency to delivering a specific type of care than others;
* "right time" indicates care is delivered in a timely manner consistent with agreed upon bench marks.
As a corollary to this definition, if all five components are present, high quality care has been delivered with the optimal use of resources, that is, waste has been eliminated and the best value has been obtained.
Appropriateness is primarily determined by analyses of the evidence of clinical effectiveness, safety, and other health system impacts.13 The practical application of appropriateness is made when these analyses are qualified by (a) clinician judgment, particularly in atypical circumstances14 and (b) societal and ethical principles and values, including patient preferences.
There are a number of perverse incentives that can contribute to the delivery of inappropriate care across the system. These exist at the system level (e.g., patients staying in hospitals longer than needed due to the lack of community services), as well as at the individual encounter level (changes in fee codes for insured medical services such as new consult fees to see a patient every six months). Physicians and payers such as governments need to work together to eliminate perverse incentives based on available medical evidence. Physician incentives should align with system needs. The challenge is getting governments, health authorities and provincial and territorial medical associations, and individual providers agreeing on system goals and objectives.
In the U.S., an innovative appropriateness initiative called Choosing Wisely was established in 2011 with the goal of improving care quality and reducing harm to patients by avoiding unnecessary interventions, with the added benefit of possible cost reductions.15 The initiative challenged specialty societies to identify five clinical activities in their field that are generally of little value or are potentially harmful to patients.16
In Canada, CMA's 2013 General Council called for the formation of a collaborative working group to develop specialty-specific lists of clinical tests/interventions and procedures for which benefits have generally not been shown to exceed the risks. Choosing Wisely Canada was launched on April 2, 2014 with the release of eight lists produced by nine specialty societies (one list was released jointly by the CMA's Forum on General and Family Practice Issues (GP Forum) and the College of Family Physicians of Canada (CFPC)). Twelve additional medical specialty societies released lists in October 2014. The Choosing Wisely Canada campaign is endorsed and supported by over 35 national specialty societies representing a broad spectrum of physicians, as well as by all provincial medical associations, patient organizations, accrediting bodies and others (Website: www.choosingwiselycanada.org). Choosing Wisely Canada aims to promote physician-patient communication about unproductive care and conserve resources by eliminating unneeded activities. This initiative also serves as an example of the role of public education campaigns to help improve appropriate care.
The development of a Canadian version of the Choosing Wisely initiative assists in operationalizing the Institute for Healthcare Improvement's (IHI) Triple Aim concept of better care, better health, better value. Specific benefits include:
* Improving accountability by providing transparent, evidence-informed care;
* Facilitating patients to make the right care decisions;
* Enhancing physician-patient relationships: improve communication and decision-making between patients and their physician; and
* Reducing clinical inefficiencies.
The ultimate objective and impetus for adopting a Choosing Wisely initiative must be to improve patient outcomes. Cost savings to the system should occur as a byproduct. Physicians are in the best position to identify which medical services are unnecessary.
Both patients and providers need to be aware of the costs associated with each treatment option, recognizing there is a balance to strike between cost and value. To facilitate this process, the CMA recommends:
6. Making available data on the cost and cost-effectiveness of treatment options at the point of care.
7. Collecting information to evaluate cost-effective care.
8. Posting costs generated by requests for diagnostic and laboratory tests in electronic medical records.
Evaluation should take place to ensure the posting of costs is targeted to areas where it will be most effective.
2.2 Operational inefficiencies
Examples of operational waste include: undertaking tests or procedures more frequently than clinically necessary (e.g., duplication of tests); unnecessary time spent waiting for medical services or time wasted from processes that add little value; using brand drugs for patients who get equal benefit from generics; and health and cost consequences of medical errors or the use of defective medical devices.
These system inefficiencies can amount to very significant costs to the health care system, patients and the economy. For instance, lengthy waits can have serious health consequences for patient outcomes and result in the substitution of additional health care services while waiting (e.g., use of pain medication). A 2008 study calculated the economic impact of excessive wait times for five procedures (hip and knee replacement surgery, MRIs, CABG surgery and cataract surgery) in all 10 provinces. It found that, in addition to the obvious emotional, physical and financial toll endured by patients and their families, lengthy waits for these medical treatments cost Canada's economy an estimated $14.8 billion overall in 2007 in reduced economic activity by patients ($16.9 billion in 2014 dollars). This included a $4.4 billion reduction in federal and provincial government revenues.17
Notwithstanding a shortage in health care infrastructure, there is general consensus that not all hospital infrastructure is used to its fullest capacity, contributing to lengthy wait times for many patients. This can include excessive turnover time between cases or limited operating room hours that can result in the last patient of the day being unable to receive their surgery at great cost to the patient and their family. In many instances, urban hospitals must cancel surgeries due to overbooked operating room time when in smaller and rural communities, operating rooms are not fully utilized. Strategies should be explored to enable greater use of health infrastructure resources in smaller community hospitals that will serve to enhance timely access to care for patients. This would also ensure that staff had a level of activity that would maintain their skills.
There has been significant uptake of operations research and quality improvement processes to help eliminate operational waste and address unnecessary waiting by patients. To this end, CMA will continue to work with its partners in the Wait Time Alliance to identify strategies to improve timely access to care for patients across the continuum. The CMA will also study the potential health applications of the Theory of Constraints within the Canadian health care system.18
There can also be system-wide inefficiencies in the various health systems operating in the country and in terms of how health systems interact with other systems such as economic and social support systems (e.g., lack of services to address homelessness). Changes in one component of the health care system can negatively affect the efficiency in another component. For instance, cuts made to home care services can lead to a rise in the number of alternate-level-of care (ALC) patients in hospitals, increased wait times in emergency departments, and elective surgery cancelations. A more recent source of system inefficiency has been occurring due to the piecemeal adoption of electronic medical records and information systems (EMR) throughout the country. The multitude of systems adopted by different segments of the health care system has resulted in problems with system inter-operability that often exacerbate administrative and clinical inefficiencies such as preventing the electronic attachment of test results leading to the reordering of tests.
The Canadian Institute for Health Information (CIHI) developed a model to measure and evaluate "health system efficiency" within Canada. It measures the average efficiency of health systems in Canada's health regions and the factors that help explain variations in estimates of system efficiency (measured as the reduction in potential years of life lost (PYLL) from treatable causes of death). The study found that equitable access to physician care is positively associated with efficiency.19 Unfortunately, over 4 million Canadians still do not have a regular family physician.20
In addition, the CIHI study found that factors related to the social determinants of health can also affect system efficiency (e.g., missed prevention opportunities). Frequently, the health care system is relied on to address preventable health needs that are attributable to the social determinants of health (e.g., injuries or illnesses caused by lack of affordable housing or poverty). Furthermore, these factors can negatively affect the effectiveness of any treatment provided by the health care system.21
Governments and health administrators should focus on improving efficiencies where there is the highest volume of services as new models of efficiency do not always show results in low volume areas.
2.3 Administrative inefficiencies
Health programs can be funded and administered at a variety of levels: local, regional, provincial and federal, as well as through employers. According to CIHI, administration accounted for $6.3 billion, or 3.1%, of health care costs in Canada in 2011-roughly middle of the pack among OECD countries22-but this is only the cost of providing public and private health insurance programs and the costs associated with health departments'operations.11 Generally, differences in the level of health administration can be explained in part by the type of health system and financing used such as whether multiple insurance providers exist or the extent that complex funding and billing procedures are in place.23 1
In terms of other administrative costs, we do not know how Canada has evolved over time in comparison to other sectors of the economy or how we compare internationally with respect to the effectiveness of administration expenditures.1 There have been questions about the expansion and contraction of regional health authorities in Canada over the past two decades. However, Canada does not have a detailed set of health accounts that would permit such analysis. CIHI has recently begun to report the percentage of administrative services expenses (general administration, finances, human resources and communications) as a percentage of total expenses for over 600 hospitals as part of its Canadian Hospital Reporting Project (CHRP).24
One source of administrative waste is the cost of duplicate collection and recording of health information. The health sector has been slow in adopting health information technology to help reduce this form of administrative waste.
Another cause of inefficiency is the increase in administrative burden faced by Canadian physicians and their patients. A major contributor is the rise in requests for physicians to complete third party forms from insurance companies and governments (see Appendix B for a list of examples of federal health programs and related medical forms). Different definitions of concepts are frequently used in these forms, but in many instances they are asking for similar information about the same patient. Physicians are also frequently requested to complete sick notes-the CMA believes such an absence does not require physician confirmation of illness and represents an inefficient use of scarce health care resources.25
The cumulative effect of a physician being requested to complete several forms each day can result in significant administrative burden and take away time that physicians can spend providing direct patient care. Standardizing definitions and wording on third-party forms can save time and reduce administrative errors. Physicians fully support any efforts by the private insurance industry and governments to standardize their medical forms. In addition, consideration should be given to instances where other designated providers can be tasked with completing particular forms. Where suitable, electronic medical records (EMRs) can improve the completion and timely submission of third-party forms to the benefit of patients, providers and third-parties.
To address these administrative inefficiencies, the following actions have been recommended by CMA:
9. Federal and provincial auditors general design and implement a protocol for detailed enumeration of administrative costs within their health care systems, including tracking of these costs over time, and issue an annual public report.
10. CIHI conduct a detailed study of administrative costs of Canadian hospitals and regional health authorities and report the findings.
11. Harmonize and centralize, in electronic and written format, all administrative forms that physicians must fill out on behalf of their patients.
3. Innovating for efficiency
Since the late 1990s, the federal, provincial, and territorial governments, and other granting bodies have provided considerable funding for applied health services research to aid the implementation of pilot projects to improve the quality of care delivered in Canada. However, Canada is frequently criticized for its inability to move beyond pilot projects to full implementation. One often-cited reason is the lack of communication about promising innovations from one jurisdiction to another. Other reasons include regulatory barriers such as funding silos, and pilot project funding for a limited duration to prevent meaningful outcome evaluation. Physician input is a necessary condition for meaningful and sustained system innovation.26
The CMA supports:
12. Developing and testing innovative structures or programs to demonstrate clear evidence of improvement in health care outcomes and fiscal sustainability before wide-spread adoption into the Canadian health delivery system.
13. Developing policy tools that provide criteria for identifying barriers to quality, efficiency and equity in emerging models of health care delivery.
14. Creating a registry of physician-managed health care transformation projects. This registry should outline the challenges and lessons learned associated with each project for those interested in adopting similar projects.
Addressing efficiency challenges in the Canadian health care system can improve the quality, continuity, and comprehensiveness of care, while making the system more cost-effective and sustainable. Many components of the health care inefficiencies set out by Bentley et al are now being considered by governments. Physician input is a necessary condition for meaningful system improvement and innovation. Physicians should practice high quality, evidence-informed health care, and advocate for cost-effective allocation of scarce resources. Canada's physicians are taking a leading role on this matter through such initiatives as Choosing Wisely Canada.
Clinical Practice Guidelines (CPGs) recommended by
The Health Care Innovation Working Group of the Council of the Federation
The group recommended each province and territory work with their health authorities to adopt the following CPGs:
* The C-CHANGE guidelines for cardiovascular disease published by the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE) to reduce guideline variations and confusion among care providers.
* Harmonized guidelines for diagnosis, which include:
o Laboratory testing (e.g., urine analysis, ECGs)
o Risk stratification strategies (e.g., family history, lifestyle choices, and diabetic patients).
* Harmonized guidelines for treatment, which include:
o Establishing treatment targets (e.g., limiting alcohol consumption, healthy body weight, glycemic or glucose targets)
o Health behavior interventions (e.g., balanced heart healthy diet, limiting salt intake, smoking cessation)
o Pharmacological therapy (e.g., assessment of drug and drug interactions, co-morbidities).
Examples of federal health programs and related medical forms
physicians are frequently requested to complete
* Canada Pension Plan Disability
* Disability Tax Credit
* Employment Insurance (Sickness Benefits Claim)
* Non-Insured Health Benefits (for First Nations people and Inuit)
* Veterans Disability Pension
* Compassionate Care Leave
* Exception/Limited Use Drug Request Form (to permit access to drugs not on provincial formularies)
* Interim Federal Health Program
* Canadian Adverse Drug Reaction Monitoring forms
1 Organisation for Economic Co-operation and Development. Health care systems: getting more value for money. OECD Economics Department Policy Note No. 2. Paris: The Organisation; 2010.
2 Canadian Institute for Health Information. Developing a model for measuring the efficiency of the health system in Canada. Ottawa: The Institute; 2012. Available: https://secure.cihi.ca/free_products/HS_Efficiency_Tech_Report_EN-web.pdf (accessed 2013 Apr 30).
3 Organisation for Economic Co-operation and Development. OECD economic surveys: Canada 2012. Paris: OECD Publishing; 2012. Available: http://dx.doi.org/10.1787/eco_surveys-can-2012-enOECD
4 Bentley T, Effros R, Palar K, et al. Waste in the U.S. health care system: a conceptual framework. Milbank Q. 2008;86(4):629-59.
5 Wennberg J, Gittelson A. Small area variations in health care delivery. Science. 1973;182:1102-8.
6 Field MJ, Lohr KN. Clinical practice guidelines: directions for a new program. Washington (DC): National Academy Press; 1990. p. 38.
7 Canadian Medical Association. Handbook on clinical practice guidelines. Ottawa: The Association; 2007.
8 The Canadian Institutes of Health Research (CIHR) has launched a Strategy for Patient Oriented Research and one of its core elements is the improvement of guideline development, dissemination and uptake through support for guideline development and dissemination. Canadian Institutes of Health Research. Canada's strategy for patient-oriented research: improving health outcomes through evidence-informed care. Ottawa: The Institutes; 2011. Available: www.cihr-irsc.gc.ca/e/documents/P-O_Research_Strategy-eng.pdf (accessed 2012 Feb 22).
9 Canadian Medical Association. CMA Infobase: clinical practice guidelines (CPGs). Available: www.cma.ca/En/Pages/clinical-practice-guidelines.aspx (accessed 2012 Feb 22).
10 Council of the Federation Working Group. From innovation to action - the first report of the Health Care Innovation Working Group. Available: www.canadaspremiers.ca/phocadownload/publications/health_innovation_report-e-web.pdf (accessed 2013 Apr 25).
11 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2013. Ottawa: The Institute; 2013. Available: https://secure.cihi.ca/free_products/NHEXTrendsReport_EN.pdf.
12 Canadian Institute for Health Information. Health care in Canada 2010. Ottawa: The Institute; 2010. Available: https://secure.cihi.ca/free_products/HCIC_2010_Web_e.pdf (accessed 2014 Oct 7).
13 Canadian Medical Association. Appropriateness. Ottawa: The Association; 2014. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-05.pdf.
14 Goldberger JJ, Buxton AE. Personalized medicine vs guideline-based medicine. JAMA. 2013;309(24):2559-60.
15 Siwek J. Choosing wisely: top interventions to improve health and reduce harm, while lowering costs. Am Fam Physician. 2012;86(2):128-33.
16 The Good Stewardship Working Group. The "top 5" lists in primary care. Arch Intern Med. 2011;171(15):1385-90.
17 Centre for Spatial Economics. The economic cost of wait times in Canada. Ottawa: The Centre; 2008. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/EconomicReport-e.pdf (accessed 2014 Apr 14).
18 Knight A. The theory of constraints in health and social care. Aldbury (UK): QFI Consulting; 2011.
19 Canadian Institute for Health Information. Measuring the level and determinants of health system efficiency in Canada. Ottawa: The Institute; 2014 Apr. Available: https://secure.cihi.ca/free_products/HSE_TechnicalReport_EN_web.pdf (accessed 2014 Feb 5).
20 Statistics Canada. Access to a regular medical doctor, 2012. Available: www.statcan.gc.ca/pub/82-625-x/2013001/article/11832-eng.htm (accessed 2014 Jan 5).
21 Canadian Medical Association. Health care in Canada: What makes us sick? Town hall report. Ottawa: The Association; 2013 Jul. Available: www.cma.ca/Assets/assets-library/document/fr/advocacy/What-makes-us-sick_en.pdf.
22 Organisation for Economic Co-operation and Development. Guidelines to improve estimates of expenditure on health administration and health insurance. Paris: The Organisation; 2013 Dec.
23 Himmelstein DU, Jun M, Busse R, et al. A comparison of hospital administrative costs in eight nations: U.S. costs exceed all others by far. Health Aff (Millwood). 2014;33(9):1586-94.
24 Canadian Institute for Health Information. Canadian Hospital Reporting Project (CHRP). Available: www.cihi.ca/CIHI-ext-portal/internet/EN/Home/home/cihi000001 (accessed 2014 Mar 20).
25 Canadian Medical Association. Short-term illness certificate. Ottawa: The Association; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-06.pdf
26 Lee TH, Cosgrove T. Engaging doctors in the health care revolution. Harv Bus Rev. 2014;92(6):104-11, 138.
HEALTH IN ALL POLICIES
Despite significant investments in health and improvements in medical treatment and technologies, health outcomes in Canada have not been moving in the right direction. Chronic diseases such as diabetes and the corresponding risk factors, among them obesity, continue to rise. This negative health status can undermine not only individual health but the productivity and prosperity of the country as well.1 As noted in the Adelaide Statement on Health in All Policies, "Good health enhances quality of life, improves workforce productivity, increases the capacity for learning, strengthens families and communities, supports sustainable habitats and environments, and contributes to security, poverty reduction and social inclusion."2
Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.3 Many studies show that people low on the socio-economic scale are likely to carry a higher burden of just about any disease.4 Poverty accounts for 24% of person years of life lost in Canada (second only to 30% for neoplasms).5 These numbers demonstrate a need to rethink the way we work to improve the health of the Canadian population. While a strong health care system is vital, changes to our health system alone will not be sufficient to improve health outcomes or reduce the disparities that currently exist in disease burden and health risks.
Using health determinants as a focus means that most health promotion and prevention efforts will take place outside of the health and medical care service.6 Canadians must be supported to make the choices that keep them healthy and reduce their risks of injury and disease. However, many face barriers in their physical, social and economic environments which make these healthy choices difficult. What is necessary is a coordinated effort across government sectors to ensure that all policy decisions serve to increase opportunities for health. As noted by the former Minister of Health and Welfare, Jake Epp, "it is not an overstatement to say that public policy has the power to provide people with the opportunities for health, as well as to deny them such opportunities... All policies having a direct bearing on health need to be coordinated."7
Improving population health and reducing inequities should be an overall objective for all governments in Canada. Not only will it help to reduce costs to the health system, it will also increase economic growth as healthier people lose fewer days of work and contribute to overall economic productivity.8 As laid out in the principles to Guide Health Care Transformation, "Coordinated investments in health promotion and disease and injury prevention, including attention to the role of the social determinants of health, are critical to the future health and wellness of Canadians and to the viability of the health care system.9"
The utilization of such an approach is not new. Governments from England to Finland to New Zealand have increasingly recognized the importance of the social determinants of health and have developed national strategies accordingly. These strategies, often referred to as 'health in all policies,' call for a whole of government approach where cross-departmental collaboration is established at the highest government level to increase the health of the population and reduce inequalities.10 The World Health Organization defines health in all policies as follows:
Health in all Policies (HiAP) is an approach to public policies across sectors that systematically takes into account the health and health systems implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity. A HiAP approach is founded on health-related rights and obligations. It emphasizes the consequences of public policies on health determinants, and aims to improve the accountability of policy-makers for health impacts at all levels of policy-making.11
This approach looks at all policies that have a health impact not just those in the health sector. Policies are reviewed for their potential impact on population health and health system utilization.12
There are many ways that a HiAP approach can be implemented. Examples include:
inter-ministerial and inter-departmental committees; community consultations and Citizens' Juries; cross-sector action teams; partnership platforms; integrated budgets and accounting; Health Lens Analyses; cross-cutting information and evaluation systems; impact assessments; joined-up workforce development; and legislative frameworks.13
A Plan for Canada
Role of the Federal Government:
While the provinces and territories have constitutional authority for the majority of health system delivery, the federal government has a significant role in health: through system oversight, Canada Health Act; delivery to certain populations, Canada's Aboriginal peoples; as well as accountability and pan-Canadian initiatives for the various health systems. Additionally, the federal government has significant control over areas such as taxation, food security and agriculture, justice, transportation safety and income security (eg child tax benefits, Old- Age Security). All of these can have a marked impact on both individual and population health.
As a result of these responsibilities the Canadian government needs to adopt a clear mandate to focus on the health of the population. Actions must be taken to provide Canadians with the ability to make healthy choices. All legislation must be subject to a health lens to determine potential health implications so as to minimize or mitigate any negative consequences and maximize opportunities for health benefits. Given the central coordinating function of Cabinet in policy setting and delivery, this would be an ideal place to incorporate a HiAP approach.
1. CMA recommends that the federal government acknowledge the relationship of the social determinants of health on the health of the population as well as the demands of the health care system and that it implement a Health in All Policies approach for all cabinet decision-making.
While Cabinet should serve as the central decision-making body for a HiAP approach, there must be formal and sustainable structures that allow timely analysis of the health consequences of policy decisions, which appropriately engage stakeholders, and which ensure that health impacts are actually considered in policy decision-making.14
Such an approach will require some form of enabling legislation as well as benefits for departments that conduct HiAP analysis. In Quebec, for example, all policies are required to undergo a review of health impacts under Section 54 of the 2002 Quebec Public Health Act.15
In addition, it is likely that a lead agency will need to be appointed to facilitate the necessary data collection/analysis to review policies. In the Netherlands health impact assessments are the responsibility of the Department of Intersectoral Policy at the Netherlands School of Public Health.16 Since 2000, the Swedish National Public Health Institute (SNIPH) has been tasked with developing methodology in strategically important areas and with supporting the application of health assessments on the central, regional and local level.17 In England, the Public Health Observatories play a key role in providing data and analysis for health impact assessments.18
A significant barriers to HiAP in Canada is the existing data infrastructure. Hundreds of major and minor publications speak to the volume of analyses undertaken on health and health systems every year in Canada. Despite this effort, Canadian policy makers and the public do not fully understand how health system vs. non-health factors contribute to the health outcomes observed or the picture of overall health. The available data tends to focus on the health care system, sickness and the measurement of sickness related risks. What is missing is a way of organizing the data which provides greater insight for planners and greater accountability for all Canadians. This capacity will need to be developed in order to properly implement a HiAP approach.
2. CMA recommends that the federal government provide the necessary enabling environment to allow for the application of a health in all policies approach in all new policy development.
As the experiences from other countries demonstrate there is some value in selecting a few Ministries to begin the process. Once selected the Ministries should be responsible for starting the process and screening any new policies. If there is a potential health impact they would then contact the centralized resource to conduct the analysis and produce a report with potential impacts and recommendations for change. This report would go back to the originating Ministry for review and modification of the policy as necessary. Changes should be highlighted and the revised policy should be sent with the health analysis report to Cabinet for final decision-making. This will help to improve the policy and will create greater awareness among all Cabinet members of the potential health implications of various policies.
3. CMA recommends that the Federal Minister of Health work with Cabinet to select appropriate Ministries to begin the implementation of the health in all policies approach.
Role of Health Care Sector:
Government is not the only group with a role in HiAP. The health sector, including Canada's physicians can work to ensure that the policy environment promotes health. By working with governments at all levels, physicians can uses their vast knowledge and expertise to provide evidence regarding potential health implications, and promote the development of evidence-informed decision making. In addition, they can work with partners both within and outside of the health sector to advocate as necessary for policy improvements.19
4. CMA recommends that physicians and other health care providers use their knowledge and expertise to support governments in the development of evidence-informed policy which promotes the health of the population.
Investments in the health system will only go so far in improving the health of the population. Population health approaches must tackle the wider social determinants of health. To do so the government must consider health in all the policies that it develops.
1 Reeves, Richard A Liberal Dose? Health and Wellbeing - the Role of the State: An Independent Report. 2010. Available: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_111695.pdf
2 World Health Organizatio. Adelaide Statement on Health in All Policies: moving toward a shared governance for health and well-being. Geneva:The Organization; 2010. Available: www.who.int/social_determinants/hiap_statement_who_sa_final.pdf (accessed 2015 Apr 16).
3 Keon, WJ, Pépin L. (2008) Population Health Policy: Issues and Options. Ottawa: The Senate of Canada; 2008. Available at: www.parl.gc.ca/Content/SEN/Committee/392/soci/rep/rep10apr08-e.pdf
4 Dunn JR. The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Toronto :The Health Determinants Partnership; 2002 Available: http://en.healthnexus.ca/sites/en.healthnexus.ca/files/resources/widening_income_equalities.pdf (accessed 2015 Apr 16)
5 Wilkins R, Berthelot J-M, Ng E. Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Statistics Canada.Health Rep. 2002:13(Supplement): 10.
6 Knutsson I, Linell A Health impact assessment developments in Sweden. Scand J Public Health. 2010;38:115-120.
7 Epp, J. Achieving health for all: a framework for health promotion. Ottawa: Health and Welfare Canada; 1986. Available: www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/1986-frame-plan-promotion/index-eng.php
8 Munro, D Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health. Ottawa: Conference Board of Canada; 2008.Available: www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb
9 Canadian Medical Association, Canadian Nursese Association. Principles for Health Care Transformation in Canada. Ottawa: The Associations; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-13.pdf
10 St-Pierre L. Governance Tools And Framework For Health In All Policies. Available: www.rvz.net/uploads/docs/Achtergrondstudie_-_Governance_tools_and_framework1.pdf
11 World Health Organization, Government of South Australia. Adapted from WHO Working Definition prepared for the 8Th Global Conference on Health Promotion, Helsinki, 10-14 June 2013.
12 Ollila E, Baum F, Pe ña S. Introduction to health in all policies and the analytical framework of the book. In Leppo K, Ollila E, Pera S, et al., editors. Health in all policies: seizing opportunities, implementing policies. Chap. 1. Finland: Ministry of Social Affairs and Health; 2013. Available: www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf.
13 World Health Organization, Government of South Australia. Adelaide Statement on Health in All Policies: moving towards a shared governance for health and well-being. Geneva: The Organization; 2010. Available: www.who.int/social_determinants/hiap_statement_who_sa_final.pdf (accessed October 18, 2014)
14 Rudolph, L, Caplan J, Mitchell C, et al. Health in All Policies: Improving Health Through Intersectoral Collaboration. Washington(DC): Institute of Medicine. Available: www.phi.org/uploads/application/files/q79jnmxq5krx9qiu5j6gzdnl6g9s41l65co2ir1kz0lvmx67to.pdf (accessed October 21, 2014).
15 National Collaborating Centre for Healthy Public Policy. Implementation of Sectin 54 of Quebec's Public Health Act. Quebec: The Centre; 2012. Available at: www.ncchpp.ca/docs/Section54English042008.pdf
16 Wright, J, Parry J, Scully EInstitutionalizing policy-level health impact assessment in Europe: Is coupling health impact assessment with strategic environmental assessment the next step forward? Bull World Health Orga. 2005;83(6):472-7
17 Knutsson I, Linell A Health impact assessment developments in Sweden. Scand J Public Health. 2010;38(2):115-20
18 St-Pierre L. Governance Tools And Framework for health in all policies. Available: www.rvz.net/uploads/docs/Achtergrondstudie_-_Governance_tools_and_framework1.pdf
19 Leppo K, Tangcharoensathien V. The health sector's role in HiAP. In Leppo K, Ollila E, Pera S, et al., editors. Health in all policies: seizing opportunities, implementing policies. Chap. 14. Finland: Ministry of Social Affairs and Health; 2013.
Available: www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf. (accessed October 18, 2014)
COMPLEMENTARY AND ALTERNATIVE MEDICINE
This statement discusses the Canadian Medical Association's (CMA) position on complementary and alternative medicine (CAM). CAM, widely used in Canada, is increasingly being subject to regulation. The CMA's position is based on the fundamental premise that decisions about health care interventions used in Canada should be based on sound scientific evidence as to their safety, efficacy and effectiveness - the same standard by which physicians and all other elements of the health care system should be assessed. Patients deserve the highest standard of treatment available, and physicians, other health practitioners, manufacturers, regulators and researchers should all work toward this end. All elements of the health care system should "consider first the well-being of the patient."1 The ethical principle of non-maleficence obliges physicians to reduce their patient's risks of harm. Physicians must constantly strive to balance the potential benefits of an intervention against its potential side effects, harms or burdens. To help physicians meet this obligation, patients should inform their physician if the patient uses CAM.
CAM in Canada
CAM has been defined as "a group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine."i This definition comprises a great many different, otherwise unrelated products, therapies and devices, with varying origins and levels of supporting scientific evidence. For the purpose of this analysis, the CMA divides CAM into four general categories:
* Diagnostic Tests: Provided by CAM practitioners. Unknown are the toxicity levels or the source of test material, e.g., purity. Clinical sensitivity, specificity, and predictive value should be evidence-based.
* Products: Herbal and other remedies are widely available over-the-counter at pharmacies and health food stores. In Canada these are regulated at the federal level under the term Natural Health Products.
* Interventions: Treatments such as spinal manipulation and electromagnetic field therapy may be offered by a variety of providers, regulated or otherwise.
* Practitioners: There are a large variety of practitioners whose fields include chiropractic, naturopathy, traditional Chinese and Ayurvedic medicine, and many others. Many are unregulated or regulated only in some provinces/territories of Canada.
Many Canadians have used, or are currently using, at least one CAM modality. A variety of reasons has been cited for CAM use, including: tradition; curiosity; distrust of mainstream medicine; and belief in the "holistic" concept of health which CAM practitioners and users believe they provide. For most Canadians the use is complementary (in addition to conventional medicine) rather than alternative (as a replacement). Many patients do not tell their physicians that they are using CAM.
Toward Evidence-Informed Health Care
Use of CAM carries risks, of which its users may be unaware. Indiscriminate use and undiscriminating acceptance of CAM could lead to misinformation, false expectations, and diversion from more appropriate care, as well as adverse health effects, some of them serious.
The CMA recommends that federal, provincial and territorial governments respond to the health care needs of Canadians by ensuring the provision of clinical care that continually incorporates evidence-informed technological advances in information, prevention, and diagnostic and therapeutic services.2 Physicians take seriously their duty to advocate for quality health care and help their patients choose the most beneficial interventions. Physicians strongly support the right of patients to make informed decisions about their medical care. However, the CMA's Code of Ethics requires physicians to recommend only those diagnostic and therapeutic procedures that they consider to be beneficial to the patient or to others.3 Until CAM interventions are supported by scientifically-valid evidence, physicians should not recommend them. Unless proven beneficial, CAM services should not be publicly funded. To help ensure that Canadians receive the highest-quality health care, the CMA recommends that CAM be subject to rigorous research on its effects, that it be strictly regulated, and that health professionals and the public have access to reliable, accurate, evidence-informed information on CAM products and therapies. Specific recommendations are provided below:
a) Research: Building an Evidence Base
To date, much of the public's information on CAM has been anecdotal, or founded on exaggerated claims of benefit based on few or low-quality studies. The CMA is committed to the principle that, before any new treatment is adopted and applied by the medical profession, it must first be rigorously tested and recognized as evidence-informed.4 Increasingly, good-quality, well-controlled studies are being conducted on CAM products and therapies. The CMA supports this development. Research into promising therapies is always welcome and should be encouraged, provided that it is subject to the same standards for proof and efficacy as those for conventional medical and pharmaceutical treatments. The knowledge thus obtained should be widely disseminated to health professionals and the public.
b) An Appropriate Regulatory Framework
Regulatory frameworks governing CAM, like those governing any health intervention, should enshrine the concept that therapies should have a proven benefit before being represented to Canadians as effective health treatments.
i) Natural Health Products. Natural health products are regulated at the federal level through the Natural Health Products Directorate of Health Canada.
The CMA believes that the principle of fairness must be applied to the regulatory process so that natural health products are treated fairly in comparison with other health products.5 The same regulatory standards should apply to both natural health products and pharmaceutical health products. These standards should be applied to natural health products regardless of whether a health claim is made for the product. This framework must facilitate the entry of products onto the market that are known to be safe and effective, and impede the entry of products that are not known to be safe and effective until they are better understood. It should also ensure high manufacturing standards to assure consumers of the products' safety, quality and purity. The CMA also recommends that a series of standards be developed for each natural health product. These standards should include:
* manufacturing processes that ensure the purity, safety and quality of the product;
* labelling standards that include standards for consumer advice, cautions and claims, and explanations for the safe use of the product to the consumer.6
The CMA recommends that safety and efficacy claims for natural health products be evaluated by an arm's length scientific panel, and claims for the therapeutic value of natural health products should be prohibited when the supportive evidence does not meet the evidentiary standard required of medications regulated by Health Canada.7 Claims of medical benefit should only be permitted when compelling scientific evidence of their safety and efficacy exists.8
The Canadian Medical Association advocates that foods fortified with "natural health" ingredients should be regulated as food products and not as natural health products
The CMA recommends that the regulatory system for natural health products be applied to post-marketing surveillance as well as pre-marketing regulatory review. Health Canada's MedEffect adverse reaction reporting system now collects safety reports on Natural Health Products. Consumers, health professionals and manufacturers are encouraged to report adverse reactions to Health Canada.
ii) CAM Practitioners. Regulation of CAM practitioners is at different stages. The CMA believes that this regulation should: ensure that the services CAM practitioners offer are truly efficacious; establish quality control mechanisms and appropriate standards of practice; and work to develop an evidence-informed body of competence that develops with evolving knowledge.
Just as the CMA believes that natural health products should be treated fairly in comparison with other health products, it recommends that CAM practitioners be held to the same standards as other health professionals. All CAM practitioners should develop Codes of Ethics that insure practitioners consider first the best interests of their patients.
Among other things, associations representing CAM practitioners should develop and adhere to conflict of interest guidelines that require their members to:
* Resist any influence or interference that could undermine their professional integrity;9
* Recognize and disclose conflicts of interest that arise in the course of their professional duties and activities, and resolve them in the best interests of patients;10
* Refrain, for the most part, from dispensing the products they prescribe. Engaging in both prescribing and dispensing , whether for financial benefit or not, constitutes a conflict of interest where the provider's own interests conflict with their duty to act in the best interests of the patient.
c) Information and Promotion
Canadians have the right to reliable, accurate information on CAM products and therapies to help ensure that the treatment choices they make are informed. The CMA recommends that governments, manufacturers, health care providers and other stakeholders work together to ensure that Canadians have access to this information. The CMA believes that all natural health products should be labeled so as to include a qualitative list of all ingredients. 11 Information on CAM should be user-friendly and easy to access, and should include:
* Instructions for use;
* Indications that the product or therapy has been convincingly proven to treat;
* Contraindications, side effects and interactions with other medications;
* Should advise the consumer to inform their health care provider during any encounter that they are using this product.12
This information should be provided in such a way as to minimize the impact of vested commercial interests on its content.
In general, brand-specific advertising is a less than optimal way of providing information about any health product or therapy. In view of our limited knowledge of their effectiveness and the risks they may contain risks, the advertising of health claims for natural health products should be severely restricted. The CMA recommends that health claims be promoted only if they have been established with sound scientific evidence. This restriction should apply not only to advertising, but also to all statements made in product or company Web sites and communications to distributors and the public. Advertisements should be pre-cleared to ensure that they contain no deceptive messages. Sanctions against deceptive advertising must be rigidly enforced, with Health Canada devoting adequate resources to monitor and correct misleading claims.
The CMA recommends that product labels include approved health claims, cautions and contraindications, instructions for the safe use of the product, and a recommendation that patients tell physicians that they are using the products. If no health claims are approved for a particular natural health product, the label should include a prominent notice that there is no evidence the product contributes to health or alleviates disease.
The Role of Health Professionals
Whether or not physicians and other health professionals support the use of CAM, it is important that they have access to reliable information on CAM products and therapies, so that they can discuss them with their patients.
Patients should be encouraged to report use of all health products, including natural health products, to health care providers during consultations. The CMA encourages Canadians to become educated about their own health and health care, and to appraise all health information critically.
The CMA will continue to advocate for evidence-informed assessment of all methods of health care in Canada, and for the provision of accurate, timely and reliable health information to Canadian health care providers and patients.
i Working definition used by the National Center for Complementary and Alternative Medicine of the U.S. National Institutes of Health.
1 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004.
2 Canadian Medical Association. Policy resolution GC00-196 - Clinical care to incorporate evidence-based technological advances. Ottawa (ON): The Association; 2000. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
3 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
4 Canadian Medical Association. CMA statement on emerging therapies [media release]. Ottawa (ON): The Association; 2010. Available: www.facturation.net/advocacy/emerging-therapies.
5 Canadian Medical Association. CMA statement on emerging therapies [media release]. Available: www.facturation.net/advocacy/emerging-therapies.
6 Canadian Medical Association. Brief BR1998-02 - Regulatory framework for natural health products. Ottawa (ON): The Association; 1998.
7 Canadian Medical Association. Policy resolution GC08-86 - Natural health products. Ottawa (ON): The Association; 2008.
8 Canadian Medical Association. Policy resolution GC10-100 - Foods fortified with "natural health" ingredients. Ottawa (ON): The Association; 2010. Available:
9 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004. Paragraph 7. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
10 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004. Paragraph 11. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
11 Canadian Medical Association. Brief BR1998-02 - Regulatory framework for natural health products. Ottawa: The Association; 1998.
12 Canadian Medical Association. Brief BR1998-02 - Regulatory framework for natural health products. Ottawa: The Association; 1998.
The harms associated with psychoactive prescription medicinesi including sedatives and tranquilizers1, stimulants2, and analgesics, particularly opioids3, such as oxycodone, hydromorphone and fentanyl, are a significant public health and patient safety issue.
Canada has one of the highest per capita consumption of prescription opioids in the world.4 Dispensing of medications has substantially increased in Canada, although patterns vary considerably between provinces.5 In 2011, while opioid consumption for medical purposes in morphine equivalence (ME)ii was 62mg per person globally, Canada's ME was 812mg per person.6 When comparing to other developed countries, Australia's ME was 427 and Denmark's 483. In North America, about 5% of the adult population, and substantially higher rates for teens and young adults, reported non-medical opioid use in the previous year. This rate is higher than all other illegal drugs, with the exception of marijuana.7
Psychoactive medications pose significant health and safety risks. The harms include overdoses, suicides, motor vehicle accidents, relationship and employment problems, workplace accidents and exposure to blood borne pathogens and other infections when used by injection, besides addiction.
Data are not collected systematically in Canada, making it difficult to assess the harms and track the trends and impact of the introduction of policy changes. However, practitioners have seen the significant impact of these prescription drugs on their patients and to public health. Studies in Ontario show that the number of people enrolled in methadone maintenance treatment rose from about 7,800 in 2001 to over 35,000 in 2011, where opioids have surpassed heroin as the drug used.8 Opioid-related deaths nearly tripled from 2002 to 2010, according to the Office of the Chief Coroner of Ontario.9 Another study showed that other non-opioid depressants (sedatives), such as benzodiazepines, were involved in 92% of the opioid-related deaths.10
The impact is felt particularly among vulnerable populations, such as youth, seniors, First Nations and those living in poverty. In 2013, opioids were reported as the third most common drug used by students in Ontario (after alcohol and marijuana).11 Opioid addiction rates anywhere from 43% to 85% have been reported in some Indigenous communities.12 13 While accurate data on the harms of prescription medication among seniors is lacking, it is well known that the prevalence of pain is higher among older adults and that they account for a significant proportion of prescriptions.
The "high" they produce also leads to these medications being sought after for recreational purposes and, as they are legal products, they are often more easily accessible than street drugs. Surveys with youth have shown that as much as 70% of opioids have been obtained from legitimate prescriptions to family and friends (55% were shared at no cost).14 As well, because opioids have high abuse liability and addiction potential, people have resorted to illegal behaviour to obtain them, such as doctor-shopping, forging prescribers' signatures, or buying from street dealers.
Of great concern, opioid dispensing levels are strongly correlated with increased mortality, morbidity and treatment admissions for substance use.15 16 Studies in Ontario and British Columbia have replicated similar findings in the US. Many patients were prescribed these medications and developed dependence.17
Psychoactive medications are important therapeutic tools and serve legitimate purposes, when prescribed in an appropriate manner with proper assessment, and as part of a comprehensive therapeutic strategy and monitoring. Medications, such as opioids, have been essential in areas such as palliative and cancer care and have contributed to the alleviation of suffering.
Since the 1990s, opioids have been recommended for longer-term treatment of chronic non-cancer pain, and have become widely used due in part to aggressive promotion and marketing for this indication.18 19 However, there is evidence for significant pain relief in the short term but a need for more evidence regarding maintenance of pain relief over longer periods of time, or for improved physical function.20 21 22
Important contributing factors for the increase in prescriptions are also the lack of supports and incentives for the treatment of complex cases, including availability and funding for treatment options for pain and addictions. Alternate approaches to pain management require more time with the patient. In addition, there are new highly potent opioid drugs available.23 24
Canada's physicians are deeply concerned about the harms of opioids and other psychoactive prescription medications. As prescribers, they have a fundamental role in helping to ensure safe and effective use of these drugs, and the deterrence of abuse. 25 26 27 Physicians assess patients and consider whether a prescription is clinically indicated according to best practices, as well as consider whether the benefits outweigh the risks, while screening for risk factors for substance dependence and diversion. This area can be a source of tension with patients who might seek to obtain drugs through fraudulent means.28 It is also an area which causes concern to many physicians, and this could be affecting access to adequate pain management where it is needed.29
The challenge for physicians and public policymakers is how to mitigate the harms of psychoactive prescription drug use, while ensuring that patients have access to the appropriate treatment for their clinical conditions.
Comprehensive National Strategy
Canada's physicians believe that this challenge requires a complex and multifaceted solution; and to further such a solution, the CMA recommends that Canada have a comprehensive national strategy to address the harms associated with psychoactive drugs in Canada, whether illegal or prescription-based, complementing existing strategies to address the harms associated with the two legal drugs - alcohol and tobacco. This comprehensive approach is necessary, as isolated measures can have unintended consequences, such as under-medicating people that require a medical treatment or constraining people to seek illegal drugs as an option when medications are made tamper-resistant.
The federal government has created the National Advisory Council on Prescription Drug Misuse, co-chaired by the Canadian Centre on Substance Abuse, the Coalition on Prescription Drug Misuse (Alberta) and the Nova Scotia Department of Health and Wellness, in partnership with Health Canada's First Nations and Inuit Health Branch's Prescription Drug Abuse Coordinating Committee. In its 2013 report First Do No Harm: Responding to Canada's Prescription Drug Crisis30, there are nearly 60 recommendations toward the development of a strategy to combat the harms associated with psychoactive prescription medications. However, there is much still to be done.
The CMA supports collaborative efforts by the federal and provincial/territorial governments, and by health professionals and other stakeholders, to develop and implement a comprehensive national strategy. Such a strategy should include the following:
1. Improvement of Drug Safety
Health Canada, as the agency that approves prescription drugs for use and monitors their safety once on the market, has several levers by which it can control Canadians' access to drugs. One of these is the Controlled Drugs and Substances Act (CDSA) and its regulations, which govern access to illegal products and recently has included psychoactive prescription drugs.
Because of their health and safety risks, it is important that Health Canada ensures that the CDSA subjects psychoactive substances to high levels of regulatory scrutiny during both the approval process and post-approval surveillance. The Act should require manufacturers to:
* Meet stringent pre-approval requirements. For example, Health Canada could require intensive review of pre-approval clinical trial results and of product monographs by an expert impartial review committee (including addiction, pain and public health expertise); or require that the manufacturer fulfill special conditions, such as formal post-market studies, as a condition of the drugs' approval; or even require larger sample sizes or longer study periods to assess harms;
* Adhere to restrictions on the marketing of controlled medications to health professionals and the general public. The adequacy of regulations needs to be assessed in this regard.
* Develop and cover tamper-resistant formulations of psychoactive drugs of concern. Although not a standalone solution, tamper-resistant formulations can reduce the potential for manipulation to be able to use through snorting, chewing or intravenously.
2. Enhancement of Optimal Prescribing through Evidence-Based Guidance, Education and Support for Prescribers
CMA recommends that appropriate prescribing of psychoactive medications should be addressed through evidence-based guidance and education. A strategy to support optimal therapy might include:
* Support for models of care that allow a physician to spend time with complex patients.
* Ongoing development and dissemination of clinical guidance. The Canadian Guideline for Use of Opioids to Treat Chronic Non-Cancer Pain was published in the CMAJ in 2010. CMA has co-sponsored an online CME module based on this guideline. There is interest in similar guidelines for sedatives and stimulants.
* Evaluative research to support the critical review of guidelines periodically. It is essential to review data on chronic conditions for which risks might outweigh benefits.
* Relevant, unbiased and easily accessible information for prescribers, which can readily be incorporated into everyday practice. This should include clinical decision-support tools for use at the point of care, inclusive of dosing guidelines and guidance on when to seek consultation with experts. Physicians also require tools, including those that facilitate: monitoring of effectiveness and tolerance by tracking pain and physical function; screening for past and current substance use; screening for depression; tapering of problematic or ineffective doses; among others.
* Educational programs in optimal prescribing, pain management and in the management of addictions, as part of the curriculum in medical school, and residency training as well as in continuing education. Particular support is needed for those in primary care.
* Guidance for prescribers about how to deal with conflict in their practice. This would include guidance for patient-centred educational discussions on safe opiate prescribing and use and management of addictions.
* Access to expert advice if required through such means as:
o Policies or standards of practice developed by provincial regulatory colleges of physicians, which can include limitations on prescription volume, treatment period and indications.
o Communities of practice, knowledge hubs and clinical support networks that link practitioners with experts in the field, facilitating triage and supporting front line generalists. Experts can not only provide clinical information, but can provide mentorship and personal advice about best practices.
o Feedback to practitioners about their prescribing practices, particularly if potentially concerning patterns are identified. This initiative should be facilitated by collaborative work between health care professionals and their respective provincial regulatory colleges.
o Academic detailing programs, which use personalized, one-on-one techniques to deliver impartial prescribing information to practitioners.
3. Enhancement of Optimal Prescribing through Physician Regulation and Prescription Monitoring Programs
Medicine is a regulated profession, and the provincial colleges of physicians have ultimate authority and responsibility for the oversight of physician practice. The colleges have taken a leading role in educating their members about appropriate prescribing, in monitoring prescribing practices to ensure their appropriateness and taking disciplinary action when required, and through collaborating with law enforcement agencies to detect and halt criminal diversion.
The CMA recommends that federal and provincial regulations regarding controlled substances recognize the established authority of physician regulatory colleges for the oversight of the medical profession.
While prescription monitoring programs (PMPs) exist in most provinces, they vary considerably in terms of quality, the nature of the information they require, whether health care practitioners have real-time access, and the purpose for which the data are collected. Standardization of monitoring systems across Canada according to best practices can contribute to addressing the harms associated with psychoactive prescription medication by:
* Allowing health care practitioners to identify previous or concomitant prescriptions of controlled medications with more than one practitioner at the time the prescription is requested or filled;
* Deterring interprovincial or jurisdictional fraud, by allowing health care practitioners to identify other prescriptions at the time the prescription is requested or filled; and
* Improving professional regulatory bodies' capacity for oversight and intervention by establishing a mechanism for real-time monitoring.
The CMA recommends that all levels of government work with one another and with health professional regulatory agencies to develop a pan-Canadian system of real-time prescription monitoring. As a first step, the CMA recommends the establishment of consistent national standards for prescription monitoring.
PMPs should be compatible with existing electronic medical and pharmacy record systems and with provincial pharmaceutical databases. Participation in prescription monitoring programs should not impose an onerous administrative burden on health care providers. PMPs should not deter physicians from using controlled medications when necessary.
CMA also recommends that Health Canada ensure that its legislative framework be used to facilitate and support the advancement of e-health, specifically e-prescribing. Electronic health records can help individual physicians or pharmacists identify potential diversion and double prescriptions, at the point where a prescription is written or filled. The electronic health record also facilitates the sharing of information among health professionals, and could minimize the potential administrative burden.
PMPs should conform to privacy laws, protecting patient confidentiality while enabling the sharing of necessary information. The CMA strongly recommends that Health Canada undertake a privacy impact assessment of the regulatory framework for controlled prescription drugs, and share the results with stakeholders.
4. Increase in Access to Treatment for Pain
Chronic pain affects many aspects of a person's life including their ability to work, their emotional, mental and physical health, and their quality of life. Pain costs Canada an estimated $60 Billion dollars per year; more than the cost of heart disease, cancer and diabetes.31 CMA has endorsed a national strategy for pain, developed and proposed by the Canadian Pain Coalition and Canadian Pain Society,32 which addresses four target areas: awareness and education; access; research; and ongoing monitoring.
Experts believe that improved access to specialized pain treatment could reduce inappropriate use of pain medications. Current best practices in pain management include:
* Care by an interprofessional team that could include physiotherapists, occupational therapists, psychologists and other health professionals;
* Recommendation of non-pharmaceutical interventions such as therapy for trauma and social pain, social supports and coping strategies;
* Appropriate pharmaceutical prescription options, covered by provincial formularies; and
* A focus on patient participation and empowerment.
However, specialized pain treatment programs are in short supply. Wait times are greater than one year at more than one third of publicly funded inter-professional treatment programs.33 In many parts of Canada, particularly rural and remote areas, such programs are not available. In addition, while physician visits are covered by the public health care system, services provided by other health professionals are more likely to be either covered by private health benefits or paid out of pocket, and are therefore beyond the means of many Canadians. These factors may result in heavier reliance on prescription medication as treatment for chronic pain.
The CMA recommends that all partners work to improve and promote access to specialized treatment programs for pain management, and that investments be made in research about options for treatment.
5. Increase in Access to Treatment for Addiction
Access to addiction treatment is very limited and, when available, is primarily comprised of detox or the substitution treatments with methadone or Suboxone(r) (buprenorphine and naloxone). As addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry by definition, which manifests along biological, psychological, social and spiritual dimensions, treatment must address all those areas rather than just one or another.34
The CMA supports the enhancement of access to options for addiction treatment that address different needs. Treatment programs must be coordinated and patient-centred, and address physical, psychological, social and spiritual circumstances. For example, it is important that addiction programs be culturally relevant for Indigenous communities.
Treatment programs must also be integrated within the health care system and be adequately funded to meet evidence based, best-practice guidelines.
CMA also supports the development and dissemination of practice tools and guidelines to help physicians assess the addiction potential of a patient receiving psychoactive medications, and to assist in managing patients who have addiction and related problems and complications.
6. Increase in Information through Epidemiological Surveillance
One of the challenges in dealing with prescription drug abuse, which can reflect hazardous (episodic) use, harmful (regular) use or addiction, is the incompleteness of our knowledge of the extent of the problem. Countries, such as the US and France, are able to monitor psychoactive drug use, while in Canada we still rely on unsystematically collected or locally limited data. The creation of a national surveillance system that supports the collection of systematic, standardized information would:
* Permit the thorough assessment of the problem, with the development and monitoring of indicators;
* Support the early detection of diversion or inappropriate prescribing behaviour;
* Support the establishment of best practices to address crucial issues;
* Identify research priorities; and
* Evaluate the impact of the implementation of strategies.
Sources of information should include PMPs, coroner's investigations, emergency room admissions, and poison control data, among others.
7. Prevention of Deaths due to Overdose
Overdose deaths have increased dramatically over the past ten years. The risk of harm from overdose may be compounded if recreational users are afraid to call for emergency assistance for fear of facing criminal charges. Opioid death and complications overdoses can be prevented with appropriate medication and prompt emergency response. The CMA recommends the:
* Creation and scaling up of community-based programs that offer access to naloxone and other opioid overdose prevention tools and services. Training should be made available to health workers, first responders, as well as opioid users, families and peers about the prevention of overdose fatalities.35
* Improvement of access to naloxone to reverse opioid overdoses. This should include the prescription of naloxone to high risk individuals and third parties who can assist a victim experiencing an opiate-related overdose.
* Enactment of Good Samaritan laws by all levels of government in order to protect callers from criminal charges if they call emergency services to report an overdose. 36 37
8. Provision of Information for Patients and the Public
Awareness programs that provide accurate information to patients and the general public are important, and could include:
* Information on the benefits and harms of psychoactive prescription medication use, and signs of dependence and overdose. This should include the risk of dependence and addiction associated with the use of opiates for the treatment of acute and chronic pain.
* Messages aimed at the prevention of problematic drug use among young people and other populations at risk.
* Information regarding safe medication storage and disposal, and reducing access to medications from family and friends. CMA supports national prescription drug "drop off" days, and recommends that patients be educated about the importance of routinely returning unused prescription drugs to the pharmacy.
The CMA recommends that Canada have a comprehensive national strategy to address the harms associated with psychoactive drugs in Canada, whether illegal or prescription-based. This strategy should include:
* That Health Canada require that manufacturers meet stringent pre-approval requirements, adhere to restrictions on the marketing of controlled medications to health professionals and the general public, and develop formulations of psychoactive drugs of concern that are tamper-resistant.
* Support for optimal prescribing through evidence-based guidance, education and supports, such as clinical guidance, clinical decision-support tools, educational programs, expert advice, and supportive models of care.
* The enhancement of optimal prescribing through physician regulation and the development of a pan-Canadian system of real-time prescription monitoring programs, compatible with electronic medical and pharmacy record systems, based on national standards.
* Increased access to specialized pain management and treatment, according to best practices, with investments in research.
* The enhancement of access to options for addiction treatment that address different needs, and the support for the development and dissemination of practice tools and guidelines.
* The creation of a national surveillance system that supports the collection of systematic, standardized information to better inform and track policy changes.
* The creation and scaling up of community-based programs that
* Offer access to opioid overdose prevention tools and services, including the improvement of access to medication to reverse opioid overdoses (naloxone) and the enactment of Good Samaritan laws by all levels of government.
* The provision of accurate information to patients and the general public, including safe medication storage and disposal.
i Psychoactive drugs are substances that, when taken, have the ability to change an individual's consciousness, mood or thinking processes (WHO, 2004). Psychoactive prescription drugs include sedatives (such as benzodiazepines and barbiturates), stimulants (such as amphetamines), and opioids (such as oxycodone, hydromorphone, morphine and fentanyl). [World Health Organization (2004) Neuroscience of psychoactive substance use and dependence. Available at: http://www.who.int/substance_abuse/publications/en/Neuroscience.pdf]
ii Comprises six main opioids: fentanyl, hydromorphone, methadone, morphine, oxycodone and pethidine.
1 Canadian Centre on Substance Abuse. Prescription sedatives and tranquilizers. Canadian drug summary. Ottawa: The Centre; 2013. Available: http://ccsa.ca/Resource%20Library/CCSA-Prescription-Sedatives-and-Tranquilizers-2013-en.pdf
2 Canadian Centre on Substance Abuse. Prescription stimulants. Canadian drug summary. Ottawa: The Centre; 2013. Available: http://ccsa.ca/Resource%20Library/CCSA-Prescription-Stimulants-2013-en.pdf
3 Canadian Centre on Substance Abuse. Prescription opioids. Canadian drug summary. Ottawa: The Centre; 2013. Available: http://ccsa.ca/Resource%20Library/CCSA-Canadian-Drug-Summary-Prescription-Opioids-2013-en.pdf
4 International Narcotics Control Board. Narcotics drugs: estimated world requirements for 2013; statistics for 2011. New York: United Nations; 2013.
5 Fischer B, Jones W, Murray K, et al. Differences and over-time changes in levels of prescription opioid analgesic dispensing from retail pharmacies in Canada, 2005-2010. Pharmacoepidemiol Drug Saf. 2011;20:1269-77.
6 United Nations Office on Drugs and Crime. World drug report 2014. New York: The Office; 2014. Available: www.unodc.org/documents/wdr2014/World_Drug_Report_2014_web.pdf
7 Fischer B, Keates A, Buhringer G, et al. Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world? Addiction. 2013;109:177-81.
8 Fischer B, Argento E. Prescription opioid related misuse, harms, diversion and interventions in Canada: a review. Pain Physician. 2012;15:ES191-ES203.
9 National Advisory Council on Prescription Drug Misuse. First do no harm: responding to Canada's prescription drug crisis. Ottawa: Canadian Centre on Substance Abuse; 2013.
10 Dhalla IA, Mamdani MM, Sivilotti MLA, et al. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone CMAJ. 2009;181(12): 891-6.
11 Centre for Addiction and Mental Health. Drug use among Ontario students, 1977-2013: results of the Ontario Student Drug Use and Health Survey. Toronto: The Centre; 2013. Available: www.camh.ca/en/research/news_and_publications/ontario-student-drug-use-and-health-survey/Documents/2013%20OSDUHS%20Docs/2013OSDUHS_Highlights_DrugUseReport.pdf
12 Chiefs of Ontario. Prescription drug abuse strategy: 'Take a stand.' Final report. Toronto: Chiefs of Ontario; 2010. Available: www.chiefs-of-ontario.org/sites/default/files/files/Final%20Draft%20Prescription%20Drug%20Abuse%20Strategy.pdf
13 Health Canada. Honouring our strengths: a renewed framework to address substance use issues among First Nations people in Canada. Ottawa: Health Canada; 2011. Available: http://nnadaprenewal.ca/wp-content/uploads/2012/01/Honouring-Our-Strengths-2011_Eng1.pdf
14 US Department of Health and Human Services Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. Rockville (MD): The Department; 2011. p. 25. Available: www.oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.pdf
15 Gomes T, Juurlink DN, Moineddin R, et al. Geographical variation in opioid prescribing and opioid-related mortality in Ontario. Healthc Q. 2011;14(1):22-4.
16 Fischer B, Jones W, Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005-2009. Pharmacoepidemiol Drug Saf. 2013;22(4):438-42.
17 Brands B, Blake J, Sproule B, et al. Prescription opioid abuse in patients presenting for methadone maintenance treatment. Drug Alcohol Depend. 2004;73(2):199-207.
18 Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ. 2011;343:d5142 DOI: 10.1136/bmj.d5142.
19 Manchikanti L, Atluri S, Hansen H, et al. Opioids in chronic noncancer pain: have we reached a boiling point yet? Pain Physician. 2014;17(1):E1-10.
20 Franklin GM. Opioids for chronic noncancer pain. A position paper of the American Academy of Neurology. Neurology. 2014;83:1277-84. Available: www.neurology.org/content/83/14/1277.full.pdf+html
21 Chou R, Ballantyne JC, Fanciullo GJ, et al. Research gaps on use of opioids for chronic noncancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10:147-59.
22 Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010;(1):CD006605.
23 Fischer B, Goldman B, Rehm J, et al. Non-medical use of prescription opioids and public health in Canada. Can J Public Health. 2008;99(3): 182-4.
24 Fischer B, Keates A, Buhringer G, et al. Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world? Addiction. 2013;109:177-81.
25 Silversides A. Opioid prescribing challenges doctors. CMAJ. 2009;181(8):E143-E144.
26 Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ. 2011;343:d5142.
27 Kirschner N, Ginsburg J, Sulmasy LS. Prescription drug abuse: a policy position paper from the American College of Physicians. Ann Intern Med. 2014;160:198-213.
28 Saveland C, Hawker L, Miedema B, et al. Abuse of family physicians by patients seeking controlled substances. Can Fam Physician. 2014;60:e131-6.
29 Wenghofer EF, Wilson L, Kahan M, et al. Survey of Ontario primary care physicians' experiences with opioid prescribing. Can Fam Physician. 2011;57(3):324-32.
30 National Advisory Council on Prescription Drug Misuse. First do no harm: responding to Canada's prescription drug crisis. Ottawa: Canadian Centre on Substance Abuse; 2013. Available: www.ccsa.ca/resource%20library/canada-strategy-prescription-drug-misuse-report-en.pdf
31 Canadian Pain Strategy Initiative. Rise up against pain: the Canadian Pain Strategy. Available: http://canadianpainstrategy.ca/en/home.aspx
32 Canadian Pain Coalition, Canadian Pain Society. Call to action: the need for a national pain strategy for Canada. 2011. Available: http://canadianpainstrategy.ca/media/11445/final%20nat%20pain%20strategy%20for%20can%20121511%20eng.pdf
33 Canadian Pain Coalition, Canadian Pain Society. Call to action: the need for a national pain strategy for Canada. 2011. Available: http://canadianpainstrategy.ca/media/11445/final%20nat%20pain%20strategy%20for%20can%20121511%20eng.pdf
34 American Society of Addiction Medicine. Public policy statement: definition of addiction. 2011. Available: www.asam.org/for-the-public/definition-of-addiction
35 Carter CI, Graham B. Opioid overdose prevention & response in Canada. Policy brief series. Vancouver: Canadian Drug Policy Coalition; 2013. Available: http://drugpolicy.ca/solutions/publications/opioid-overdose-prevention-and-response-in-canada/
36 Follett KM, Piscitelli A, Parkinson M, et al. Barriers to calling 9-1-1 during overdose emergencies in a Canadian context. Crit Social Work. 2014;15(1):18-28. Available: http://www1.uwindsor.ca/criticalsocialwork/system/files/Follett_Piscitelli_Parkinson_Munger_2014.pdf
37 Carter CI, Graham B. Opioid overdose prevention & response in Canada. Policy brief series. Vancouver: Canadian Drug Policy Coalition; 2013. Available: http://drugpolicy.ca/solutions/publications/opioid-overdose-prevention-and-response-in-canada/
PHYSICIAN RESOURCE PLANNING
The purpose of this policy statement is to identify the key elements required to properly undertake physician resource planning to support the delivery of appropriate medical care to all Canadians. A sustainable health care system requires effective physician resource planning and training that ensures an appropriate specialty mix that is responsive to population needs. CMA supports the need for the establishment of a coordinated national approach toward physician resource planning and an appropriately responsive undergraduate and postgraduate education system. CMA supports supply- and demand- projection models for health human resources using standardized approaches. National specialty societies should be actively engaged in physician resource planning for their respective discipline. Governments must work cooperatively with the medical profession to meet the needs of the population they serve in an affordable manner including funding the necessary infrastructure to support the appropriate number and mix of physicians.
1. Physician resource planning requires a pan-Canadian supply and needs-based projection model.
2. Infrastructure and resources as well as physician resources need to match the needs-based projection.
3. Strategies should be used throughout the undergraduate and postgraduate training system to address the current challenges matching physician resources to population needs.
4. Changing models of care delivery must be taken into consideration when developing physician resource projection models.
The purpose of this policy statement is to identify the key elements required to properly undertake physician resource planning to support the delivery of appropriate medical care to all Canadians.1
Ensuring an adequate supply of physician human resources is a major tenet of the Canadian Medical Association's (CMA) Health Care Transformation initiative.2 While the number of students enrolled in Canadian medical schools increased by over 60 percent between 2001-02 and 2011-12, some enrollment reductions are now occurring despite significant physician resource issues remaining, affecting patient care delivery across the country.
Currently, four to five million Canadians do not have a family physician. For older family physicians who may retire soon or wish to reduce their practice workload, there may be no colleagues able to take on new patients. Many new family physicians do not take on as large a roster of patients as those retiring. Even where overall supply has improved, recruiting and retaining physicians in underserved areas remains a challenge. Canada continues to license International Medical Graduates (IMGs) with 25% of practicing physicians receiving their medical degree from outside of the country3-the distribution of this group varies throughout Canada.
Physician disciplines in short supply vary by jurisdiction. Some new physicians (especially those dependent on hospital based resources) are finding it hard to secure employment in their discipline.4 Concern for the future has spread to postgraduate residents and medical students. Completing fellowships, to make physicians more marketable, are now commonplace. A major contributor to underemployment in some specialties is a lack of infrastructure and related human resources (e.g., operating room time, nursing care).
A sustainable health care system requires effective physician resource planning and training that ensures an appropriate specialty mix that is responsive to population needs. At present, there is no pan-Canadian system to monitor or manage the specialty mix. Few jurisdictions engage in formal health human resources planning and little cross-jurisdictional or pan-Canadian planning takes place. Currently, few Canadian jurisdictions have a long-term physician resource plan in place, particularly one that employs a supply and needs-based projection model. It has been almost four decades since the federal government has completed a needs-based projection of physician requirements in Canada.5
Physician resource planning must consider the population's health care needs over a longer term as the length of time to train a physician can be over a decade long depending on the specialty; this also means that practice opportunities can change during the period of training. The consequences of the lack of monitoring and management of the physician specialty mix can be long-lasting. A 2014 comparison of posted physician practice opportunities across Canada versus the number of post-graduate exits suggests a supply and demand mismatch for both family physicians (more positions posted than post-grad exits) and for medical and surgical specialists (more post-grad exits than available positions posted).6
Overall goal and considerations of physician resource planning
The overall goal of physician resource planning is to produce a self-sustaining workforce that will effectively serve the health needs of Canadians by providing an adequate supply of clinicians, teachers, researchers and administrators.
Physician resource planning should recognize the following considerations:
* Physicians in training have a dual role of learner and clinical care provider.7
* Shifts in service delivery can occur with the development of new technologies, the changing prevalence of some disease states, the emergence of new illnesses and shifting public expectations (see Appendix A: The impact of emerging health technologies and models of care on physician resource planning).
* Rural and remote communities possess unique challenges of not only attracting physicians but also in the nature of skills required to provide services.
* Physicians are required for services to patient populations who fall under federal jurisdiction including members of the Canadian Armed Forces, First Nations and Inuit, refugees and refugee claimants, veterans, and prisoners in federal penitentiaries; this includes consideration of how they are attracted and the skills they require.
* The full use of national medical services should be utilized instead of outsourcing to other countries. In instances where outsourcing of medical services occurs, Canadian training and certification standards must be met.
* The emphasis from governments and the public for 24/7 access to a wide scope of physician and health care services must be balanced with the possibility of more fragmented care from multiple physicians involved in the care of a single patient.
* There is a need for more clearly defined scopes of professional activity and optimal interactions among primary care physicians including family physicians who acquire enhanced/advanced skills to meet community needs, general specialists and subspecialists, particularly in the large urban areas where these three broad groups co-exist.
* It is also relevant to define the role and most appropriate interactions of physicians with other healthcare professionals, including but not limited to physician assistants, specially trained nurses, dieticians, therapists and pharmacists.
* The current shift to alternate payment plans and collaborative care models may, increase or decrease the non-clinical portion (e.g., research, teaching) of a physician's workload and thus increase the need for additional physicians.
* The scheduling for the provision of after-hours care can have an effect on the use of physician resources (See CMA's policy statement on Management of Physician Fatigue for more information).
* High tuition fees affect the social demographic mix of those seeking medical degrees while higher debt loads and the opportunity to practice in various models of care can influence specialty choice. 8 Similarly, advice from supervising faculty role models, negative/positive experiences during training, perceived lifestyle of the discipline, personal finances and earning potentials of medical disciplines all influence a medical student's specialty choice and in turn what health services will be available to future populations. Reliable and valid information on the current and future needs of the Canadian population can help trainees to make evidence-based decisions that allow them to select careers that match the needs of their patients.
* Patterns in the transition of retiring physicians' practices need to be identified.
It is essential to project not only the number of physicians but also some measure of their likely level of professional activity. Practice patterns may vary in response to changes in lifestyle among physicians, changing health technologies, group practices, interdisciplinary care models, and increased specialization of many generalist specialists and family physicians.
The academic sector must ensure the provision of high-quality undergraduate, postgraduate and continuing education programs, and remain internationally competitive in the recruitment and retention of a first-class teaching and research community.
Structured mentorship programs and formal career counseling should be a required component of all undergraduate and postgraduate curricula in Canada.9 Teaching institutions and postgraduate accreditation authorities need to recognize the risk in requiring students to make critical career choices before exploring all the options and should develop strategies to mitigate those risks, which may include tools for assessing aptitudes. Formal career counseling throughout medical education and training can boost employment success. Results of supply projection models should also be readily available to students and advisors so an informed choice can be made.
There is a need to ensure flexibility at the undergraduate, postgraduate, and re-entry levels of medical education, with the recognition that the requirements for specialist services may change. It also allows room for standardized transfers of residents between programs and locations and for the integration of international medical graduates (IMGs). CMA recommends that a ratio of 120 postgraduate training positions per 100 medical graduates be re-established and maintained. Canadians studying medicine abroad and other IMGs who are permanent residents or citizens of Canada must be explicitly factored into the planning for the capacity of the post-MD training system. CMA supports measures to facilitate the acculturation of IMGs.
The objective of seeking reasonable self-sufficiency for the full range of physician services must be paramount.10 Self-sufficiency is defined as ensuring that the annual output of the undergraduate and postgraduate sectors of Canadian medical schools meets the medical service needs of the Canadian public. This will reduce the need to attract physicians from countries that face a higher burden of disease whose requirements for physician services exceed those of Canada. It is important to facilitate the retention of physicians who train in the Canadian postgraduate system.
There must be adequate human and physical infrastructure to support physician training. An adequate supply of clinical educators is required to prevent training bottlenecks. Strategies that utilize untapped health infrastructure resources within and outside the academic community such as satellite or distributive medical education training sites should be considered for not only training reasons but for retention purposes as well.
Effectively matching supply to societal needs
Residency training positions should reflect current and emerging population needs and if possible, job availability at the national level. Mechanisms should be in place to assist medical training programs to adjust to changing health needs in a timely manner.
Physician resource planning can benefit from enhanced evaluation of community health needs, as established by thorough determinations of health status, epidemiological studies, input from communities and other needs assessments.
In recent years, attention has been given to augmenting the provision of care to properly respond to Canada's growing seniors' population. This will require an assessment of physician resource trends among specialties that focus on seniors' care including the capacity to deliver quality palliative end-of-life care throughout Canada.
To address geographic maldistribution, programs should train physicians in the wide spectrum of practice that is required for underserved communities-both rural and urban-as well as incorporate the involvement of the communities throughout the medical trainee life cycle. Programs to attract and retain physicians, including those from rural and underservice areas, need flexible incentives to address the professional and personal needs of physicians. Financial incentives, locum support, spousal employment, children's education and support from other specialists are key factors that need to be addressed. Also, the attraction and retention of physicians to underserved areas requires the presence of adequate technical equipment and personnel.
Exposure to patterns of community practice-including generalist training-outside large urban tertiary/quaternary centres may help attract individuals into specialties best suited for rural and regional centres. CMA encourages family physicians to maintain their skills in comprehensive family medicine, while supporting their choice to acquire additional skills that will better serve the needs of their community.
It is important to strive and budget for a critical mass of physicians required to deliver basic services to given populations to permit reasonable life-style management and the avoidance of professional isolation. Coercive measures that restrict physicians' choice of location and subsequent geographic mobility are not supported.
Concentrated efforts are needed to assist new graduates of Canadian residency programs and established physicians find optimal employment in their discipline within Canada. The issue of facilitating the mobility of physicians among provinces and territories (including locum work) requires dialogue with and cooperation from individual provincial and territorial licensing authorities.
CMA supports supply- and demand- projection models for health human resources using standardized approaches. Physician human resource plans should be reviewed on an ongoing basis, examining current supply and attrition patterns to determine if new policies are required or changes are needed to the undergraduate and postgraduate complement.
Collaborative approach to physician resource planning
Physician resource planning is complex, requiring the involvement of provincial/territorial medical associations, national specialty societies, the Royal Canadian Medical Service (Canadian Armed Forces), special medical interest groups, the medical education sector, the health care facilities sectors, governments, other health care professionals and other key stakeholders.
CMA is committed to promoting a collaborative and respectful interaction among all the disciplines within the medical profession and recognition of the unique contributions of each to an efficient, high-quality and cost-effective health care delivery system. Governments must work cooperatively with the medical profession to meet the needs of the population they serve in an affordable manner including funding the necessary infrastructure to support the appropriate number and mix of physicians. National specialty societies should be actively engaged in physician resource planning for their respective discipline.
CMA supports the establishment of a coordinated national approach toward physician resource planning and an appropriately responsive undergraduate and postgraduate education system. The recruitment and retention policies available at the provincial level can play a significant role in health human resources distribution and evolution. The federal government in conjunction with the provincial Deputy Ministers and Deans of Medicine, should continue to fund a pan-Canadian supply based planning model as laid out by the Physician Resource Planning Taskforce and extend its support to the second phase which is a comprehensive needs based planning model that will be accessible to governments and the profession.
Given the importance of a planned, open and professional approach to physician resource planning, the CMA encourages all stakeholders to permit researchers, policy planners and other relevant organizations access to their physician resources database at the national and jurisdictional level while protecting the privacy of individual physicians. The CMA will continue to seek input into the design and structure of any such national databases.
The impact of emerging health technologies and models of care on physician resource planning
As in the past, a number of technological developments11 will alter the future demand for medical services and how medicine is practiced. Examples of such technological developments include: health information technologies (HITs); technologies to support distance care and self-monitoring (e.g., telemedicine, implantable or wearable sensors); surgical robotics; advanced diagnostic testing; genomic technologies; integrated care teams; and new funding models. It is important to consider how these developments will affect future supply and training (i.e., skill sets) of physicians as part of physician resource planning.
There is little evidence about whether new technologies increase or reduce working hours.12 However, the adoption of new technologies can lead to new roles and opportunities for physicians as well as for other staff. New technologies can also lead to a greater role for patients in taking responsibility for their own health. There is extensive evidence that new technologies can improve the quality of patient care, especially when used in addition to existing care rather than as a substitution.13
A key factor in assessing the impact of new health technologies on physician resource planning is the rate of adoption and diffusion of new technologies. The rate can vary widely depending on an extensive range of factors including ease of use, safety, cost (both in terms of acquiring the technology and to train the clinician), compatibility and culture/attitudes. Not all new technologies are successfully adopted or lead to positive outcomes. Moreover, unlike other sectors, the adoption of health care technologies does not often lead to lower costs.14 The adoption can also be influenced by broader factors such as changing patient needs and the government's fiscal resources.
One key impact of emerging health technologies is a shift in the location where care is received. For instance, less invasive surgery will lead to greater use of community services for follow up care rather than in-hospital care. Likewise, the technologies can support the provision of more specialized services in small and remote communities by family physicians with the appropriate training and support.
Emerging health technologies can also impact the type of care provided. The literature suggests the impact will be felt more in sub-specialty areas with care shifting from one subspecialty to another.15 Advances in non-invasive surgical interventions will continue to drive practice convergence such as seen with cardiac related procedures.16
The accelerated use of HITs specifically could have the greatest overall impact on health human resources due to such factors as: the need for increased training to use HITs; and an increased need for health informatics specialists (both medical and non-medical).15 Automated knowledge work tools will almost certainly extend the powers of many types of workers and help drive top-line improvements with innovations and better decision making.17
The move to more collaborative care models, particularly in primary care, can be expected in the coming years. Common characteristics of these models include comprehensive chronic disease prevention, population-based services and programs, full use of electronic medical records, quality monitoring, dedicated time to team building and collaboration, and a wide range of health care providers functioning to their full scope of practice.18 Multi-disciplinary teams could also involve a wider range of providers such as IT specialists, bio-engineers and genetic counselors. While CMA has previously called for funding models to be in place to allow physicians and other health care providers to practice within the full scope of their professional activities,19 a significant issue will be how such collaborative care models can be funded by governments on a sustained basis.
Physicians and other health care providers need to be trained to effectively adopt any new technology. The literature is clear that physicians must be engaged in any discussions regarding new and current health technologies to ensure their proper assessment and successful implementation.20 Previously, CMA has called for:
* A flexible medical training system based on informed career choice to accommodate changes in medical practice and physician resource needs;
* A sufficient and stable supply of re-entry positions within the postgraduate training system to enable practicing physicians to enhance their skills or re-enter training in another discipline.21
* Recognition that scopes of practice must reflect these changes in societal needs (including the need of the public for access to services), societal expectations, and preferences of patients and the public for certain types of health care providers to fulfill particular roles and functions, while at the same time reflecting economic realities.22
1 This policy is to be used in conjunction with CMA's policy statements on Management of Physician Fatigue (2014), Flexibility in Medical Training (Update 2009), Physician Health and Well-Being (1998), Tuition Fee Escalation and Deregulation in Undergraduate Programs in Medicine (Update 2009), and Rural and Remote Practice Issues (1998).
2 Canadian Medical Association. Health Care Transformation in Canada. Change That Works, Care That Lasts. Ottawa: The Association; 2010. Available: http://www.hpclearinghouse.ca/pdf/HCT-2010report_en.pdf (accessed 2015 May 04).
3 Canadian Institute for Health Information. Physicians in Canada, 2013: Summary Report Ottawa: The Institute; 2013 Sep.
4 College of Family Physicians of Canda, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National Physician Survey 2013. Backgrounder. Available: http://nationalphysiciansurvey.ca/wp-content/uploads/2013/10/OFFICIAL-RELEASE_NPS-2013-Backgrounder_EN.pdf
5 The last federally commissioned study, the Report of the Requirements Committee on Physician Manpower to the National Committee on Physician Manpower, was published by the Minister of National Health and Welfare in 1975.
6 Research conducted by the Canadian Medical Association. Fall 2014.
7 National Steering Committee on Resident Duty Hours. Fatigue, risk and excellence: Towards a Pan-Canadian consensus on resident duty hours. Ottawa: Royal College of Physicians and Surgeons of Canada. 2013.
8 Canadian Medical Association. Tuition fee escalation and deregulation in undergraduate programs in medicine (update 2009). Ottawa" The Association; 2003 June. Available: http://policybase.cma.ca
9 The Canadian Association of Internes and Residents. CAIR Position Paper on Mentorship. June 2013. http://residentdoctors.ca/wp-content/uploads/2014/12/CAIR-Position-Paper-on-Mentorship_June-2013_en.pdf (accessed 2015 Apr 29).
10 Self-sufficiency is a key principle of the Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources' Framework for Collaborative Pan-Canadian Health Human Resources Planning. Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources. 2009. How Many Are Enough? Redefining Self-Sufficiency for the Health Workforce: A Discussion Paper. The policy is also consistent with the World Medical Association and the World Health Organization (The WHO Global Code of Practice of the International Recruitment of Health Personnel). http://www.who.int/hrh/migration/code/code_en.pdf?ua=1
11 Definition of Health Technologies (World Health Organization): "The application of organized knowledge and skills in the form of devices, medicines, vaccines, procedures and systems developed to solve a health problem and improve quality of lives."
12 Evidence Centre for Skills for Health, How do technologies impact on workforce organisation? Bristol (UK): The Centre. Available: www.skillsforhealth.org.uk/index.php?option=com_mtree&task=att_download&link_id=101&cf_id=24 (accessed 2015 Feb 02).
13 Evidence Centre for Skills for Health, How do technologies impact on workforce organisation? Bristol (UK): The Centre. Available: www.skillsforhealth.org.uk/index.php?option=com_mtree&task=att_download&link_id=101&cf_id=24 (accessed 2015 Feb 2)
14 Skinner J. "The costly paradox of health-care technology". MIT Technology Review. 2013 Sep 5.
15 Anvari M. Impact of information technology on human resources in healthcare. Healthcare Quarterly, 10(4) September 2007:84-88.
16 Social Sector Metrics Inc., Health Intelligence Inc. Physician resource planning: a recommended model and implementation framework. Final report submitted to the Nova Scotia Department of Health and Wellness. 2002 Jan 31. Available: www.doctorsns.com/site/media/DoctorsNS/PhysicianResourcePlanning-finalreport.pdf (accessed 2015 Feb 2).
17 McKinsey Global Institute, Disruptive technologies: Advances that will transform life, business, and the global economy. McKinsey & Company 2013.
18 Social Sector Metrics Inc., Health Intelligence Inc. Physician resource planning: a recommended model and implementation framework. Final report submitted to the Nova Scotia Department of Health and Wellness. 2002 Jan 31. Available: www.doctorsns.com/site/media/DoctorsNS/PhysicianResourcePlanning-finalreport.pdf (accessed 2015 Feb 02).
19 Canadian Medical Association. The Evolving Professional Relationship Between Canadian Physicians and Our Health Care System: Where Do We Stand? Ottawa: The Association; 2012
20 Steven A. Olson et al., Healthcare technology: Physician collaboration in reducing the surgical cost. Clinical Orthopaedics and Related Research. (2013) 471:1854-64.
21 Canadian Medical Association. Flexibility in Medical Training (update 2009) Ottawa: The Association; 2009.
22 Canadian Medical Association. Scopes of practice. Ottawa: The Association; 2002.
Authorizing Cannabis for Medical Purposes
The legalization of cannabis for recreational purposes came into effect with the Cannabis Act in October 2018, and patients continue to have access to cannabis for therapeutic purposes. The Cannabis Regulations have replaced the Access to Cannabis for Medical Purposes Regulations. Patients can obtain cannabis for medical purposes when a physician or nurse practitioner provides a “medical document” , authorizing its use, and determining the daily dried cannabis dose in grams.
With the authorization, patients have the choice whether to (a) buy directly from a federally licensed producer; (b) register with Health Canada to produce a limited amount for personal consumption; (c) designate someone to produce it for them; or (d) buy cannabis at provincial or territorial authorized retail outlets or online sales platforms, if above the legal age limit.
While acknowledging the unique requirements of patients suffering from a terminal illness or chronic disease for which conventional therapies have not been effective and for whom cannabis may provide relief, physicians remain concerned about the serious lack of clinical research, guidance and regulatory oversight for cannabis as a medical treatment. There is insufficient clinical information on safety and efficacy for most therapeutic claims. There is little information around therapeutic and toxic dosages and knowledge on interactions with medications. Besides the need for appropriate research, health practitioners would benefit from unbiased, accredited educational modules and decision support tools based on the best available evidence.
The Canadian Medical Association has consistently expressed concern with the role of gatekeeper that physicians have been asked to take as a result of court decisions. Physicians should not feel obligated to authorize cannabis for medical purposes.
Physicians who choose to authorize cannabis for their patients must comply with their provincial or territorial regulatory College's relevant guideline or policy. They should also be familiar with regulations and guidance, particularly:
Health Canada’s Information for Health Care Practitioners – Medical Use of Cannabis (monograph, summary and daily dose fact sheet),
the Canadian Medical Protective Association’s guidance;
the College of Family Physicians of Canada’s preliminary guidance Authorizing Dried Cannabis for Chronic Pain or Anxiety; and
the Simplified guideline for prescribing medical cannabinoids in primary care, published in the Canadian Family Physician.
The CMA recommends that physicians should:
Ensure that there is no conflict of interest, such as direct or indirect economic interest in a licensed cannabis producer or be involved in dispensing cannabis;
Treat the authorization as an insured service, similar to a prescription, and not charge patients or the licensed producer for this service;
Until such time as there is compelling evidence of its efficacy and safety for specific indications, consider authorizing cannabis only after conventional therapies are proven ineffective in treating patients’ conditions;
Have the necessary clinical knowledge to authorize cannabis for medical purposes;
Only authorize in the context of an established patient-physician relationship;
Assess the patient’s medical history, conduct a physical examination and assess for the risk of addiction and diversion, using available clinical support tools and tests;
Engage in a consent discussion with patients which includes information about the known benefits and adverse health effects of cannabis in its various forms (e.g., edibles), including the risk of impairment to activities such as driving and work;
Advise the patient regarding harm reduction strategies and the prevention of accidental exposure for children and other people;
Document all consent discussions in patients' medical records;
Reassess the patient on a regular basis for its effectiveness to address the medical condition for which cannabis was authorized, as well as for addiction and diversion, to support maintenance, adjustment or discontinuation of treatment; and
Record the authorization of cannabis for medical purposes similar to when prescribing a controlled medication.
The Cannabis Regulations provide some consistency with many established provincial and territorial prescription monitoring programs for controlled substances. Licensed producers of cannabis for medical purposes are required to provide information to provincial and territorial medical licensing bodies upon request, including healthcare practitioner information, daily quantity of dried cannabis supported, period of use, date of document and basic patient information. The Minister of Health can also report physicians to their College should there be reasonable grounds that there has been a contravention of the Narcotic Control Regulations or the Cannabis Regulations.
Approved by CMA Board February 2015
Latest update approved by CMA Board in February 2020
Palliative care is an approach that aims to relieve suffering and improve the quality of life of those facing life-limiting acute or chronic conditions by means of early identification, assessment, treatment of pain and other symptoms and support of all physical, emotional and spiritual needs. It may coexist with other goals of care, such as prevention, treatment and management of chronic conditions, or it may be the sole focus of care.
1. All Canadian residents should have access to comprehensive, quality palliative care services regardless of age, care setting, diagnosis, ethnicity, language and financial status.1
2. The Canadian Medical Association (CMA) declares that its members should adhere to the principles of palliative care whereby relief of suffering and quality of living are valued equally to other goals of medicine.
3. The CMA believes that all health care professionals should have access to referral for palliative care services and expertise.2
4. The CMA supports the integration of the palliative care approach into the management of life-limiting acute and chronic disease.3
5. The CMA advocates for the integration of accessible, quality palliative care services into acute, community and chronic care service delivery models4 that align with patient and family needs.
6. The CMA supports the implementation of a shared care model, emphasizing collaboration and open communication among physicians and other health care professionals.5
7. The CMA recognizes that the practice of assisted dying as defined by the Supreme Court of Canada is distinct from the practice of palliative care.
Access to palliative care services
8. The CMA believes that every person nearing the end of life who wishes to receive palliative care services at home should have access to them.
9. Comprehensive, quality palliative care services must be made available to all Canadians and efforts to broaden the availability of palliative care in Canada should be intensified.6
10. The CMA calls upon the federal government, in cooperation with provincial and territorial governments, to improve access to pediatric palliative care through enhanced funding, training and awareness campaigns.7
11. The CMA will engage in physician human resource planning to develop an appropriate strategy to ensure the delivery of quality palliative care throughout Canada.8
12. All physicians require basic competencies in palliative care and may require enhanced skills appropriate to their practice.
13. The CMA requests that all Canadian faculties of medicine create a training curriculum in palliative care suitable for physicians at all stages of their medical education and relevant to the settings in which they practise.9
Role of governments
14. The CMA calls on governments to work toward a common strategy for palliative care to ensure equitable access to and adequate standards for quality palliative care.10
15. The CMA recommends that all relevant legislation be amended to recognize that any person whose medical condition warrants it is entitled to receive palliative care.11
16. The CMA supports emergency funding for end-of-life care for uninsured people residing in Canada.12
In Canada, the impact of end-of-life care on both individuals and the health care system is "staggering," and the demand for this care will continue to grow as the population ages.13 It is estimated that the number of Canadians dying each year will increase by 40% to 330,000 by 2026. The well-being of an average of five others will be affected by each of those deaths, or more than 1.6 million people.14 Against this backdrop, the availability of and access to palliative care is an urgent policy and practice imperative.
There has been mounting support for, and mounting criticism of the lack of, a national strategy for palliative care.15 The delivery of palliative care varies greatly across Canada due to differences in regional demographics, societal needs, government involvement and funding structures. Similarly, funding and legislation supporting access to palliative care services vary significantly between jurisdictions.
A recent survey of Canadian physicians who provide palliative medicine found that: (1) Canada needs an adequate palliative medicine workforce; (2) primary care providers need more support for palliative care education and training; (3) palliative medicine as a distinct discipline must be further developed to better meet the complex needs of patients; and (4) Canada must ensure minimum palliative medicine standards are met.16
In an effort to address the current challenges in palliative care and improve both the quality of care and access to care, the CMA developed recommendations for a national call to action:
1. All patients should have a primary care provider that can support them with their palliative care needs or else refer these patients earlier to a palliative care team to establish goals of care.
2. Physicians should provide leadership at local, regional, provincial/territorial and federal levels to promote the establishment of integrated models of palliative care.
3. All physicians should obtain essential palliative care skills and knowledge to provide basic palliative care services to their patients.
4. Physicians should advocate for adequate and appropriate home palliative care resources so their patients can stay in their homes as long as possible.
5. Physicians should advocate for an adequate number of palliative and/or hospice care beds to meet their communities' needs.
6. Continuing care facilities and long-term care homes should have in-house palliative care physician support on their palliative care teams.
7. Physicians should support the valuable work of hospice volunteers.
8. Medical students are encouraged to look at palliative care as a rewarding career.
9. Practising palliative care physicians are encouraged, if needed, to obtain additional certified training in palliative care from either the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada.
10. Physicians acknowledge the value of and support the participation of family and friends in caring for their loved ones at the end of life.
Integrated palliative approach to care
There are four main models of palliative care delivery in Canada: integrated palliative care programs, continuing care and long-term care facilities, residential hospices, and home-based palliative care.
Palliative care was originally developed in cancer care to provide patients dying of cancer with care at the very end of life by a specialized palliative care team.17 This model has evolved significantly in response to the increasing occurrence of, and burden posed by, complex chronic disease18. Palliative care is now also provided to patients with multiple co-occurring morbidities who require multiple interventions. It is now recognized to benefit all those living with life-limiting acute or chronic conditions, including, or perhaps especially, when it is initiated earlier in the disease trajectory.
Evidence shows that integrated and early provision of palliative care leads to: (1) better outcomes than those obtained with treatment alone (e.g., improvements in symptoms, quality of life and patient satisfaction; positive effects on emotional wellness; decreased suffering; and at times increased longevity) and (2) better use of resources (e.g., less burden on caregivers, more appropriate referrals to hospice palliative care, more effective use of palliative care experts, less use of emergency and intensive interventions and decreased cost of care).19-20-21-22 Taken together, these studies validate the benefits of integrating palliative care services with standard treatment and involving palliative care providers early, a collaborative approach that transcends the conventional view that palliative care is care delivered at the very end of life.
At present, there is strong support for the development and implementation of an integrated palliative approach to care. Integration effectively occurs:
* throughout the disease trajectory;
* across care settings (primary care, acute care, long-term and complex continuing care, residential hospices, shelters, home);
* across professions/disciplines and specialties;
* between the health care system and communities; and
* with changing needs from primary palliative care through to specialist palliative care teams.
The integrated palliative approach to care focuses on meeting a person's and family's full range of physical, psychosocial and spiritual needs at all stages of frailty or chronic illness, not just at the end of life.23 It is provided in all health care settings. The palliative approach to care is not delayed until the end stages of an illness but is applied earlier to provide active comfort-focused care and a positive approach to reducing suffering. It also promotes understanding of loss and bereavement (Fig. 1).
Specialized palliative units and hospices are essential for end-of-life care for some individuals but are not appropriate for all persons facing life-limiting chronic conditions. When a palliative approach is offered in multiple settings, people and their families can receive better care through the many transitions of chronic conditions like dementia, lung, kidney and heart diseases, and cancer. This requires that all physicians be competent in initiating a primary palliative approach: they must be able to engage in advance care planning discussions, ask about physical and emotional symptoms and make appropriate, timely referrals to other providers and resources. Primary care physicians may need to develop more expertise in palliative care. A cadre of expert palliative care physicians will be required to provide care in complex cases, engage in education and research, and provide support for health professional colleagues providing palliative care in multiple settings. All health professionals must be able to practise competently in an integrated palliative approach to care.
At the heart of an integrated palliative approach to care are a patient and family surrounded by a team of multidisciplinary professionals and community providers (Fig. 2). While team members vary depending on the needs of the patients and families, the principles of whole-person care and family care do not change. This allows patients and families to have their symptoms managed, receive care in the setting of their choice, engage in ongoing discussions about their preferences for care and experience a sense of autonomy in living their lives well.
A report on The Way Forward, a project of the Quality End-of-Life Coalition of Canada and the Canadian Hospice Palliative Care Association, summarizes the situation as follows: "Only a small proportion of Canadians will need the kind of complex, intensive or tertiary hospice palliative care provided by expert palliative care teams in institutional settings, such as residential hospices and acute care hospitals. However, everyone who is becoming frail or is faced with a chronic illness could benefit from certain key palliative care services. As our population ages, we must ensure that all Canadians have access to palliative services integrated with their other care that will help them manage symptoms, enhance their lives, give them a greater sense of control, and enable them to make informed decisions about the care they want. More equitable access to palliative care integrated with their other care will enable more Canadians to live well with their illness up to the end of life. It will also enable more people to receive care in the setting of their choice and reduce the demand on acute care resources." 24
Access to palliative care services
There are currently no reliable data on the number of specialized or semi-specialized palliative care physicians in Canada. It is difficult to count these physicians because palliative care has not historically existed as a specialty. Physicians practising palliative care have a wide variety of backgrounds and training, and many provide palliative care on a part-time basis. The Canadian Society of Palliative Care Physicians is currently working with partner organizations including the CMA, the Royal College of Physicians and Surgeons and the College of Family Physicians of Canada to better define the different types of palliative care physicians to conduct a meaningful count.
On the question of access, studies have found that palliative care services are not aligned with patient preferences. For example, while 70% of hospitalized elderly patients reported wanting comfort measures rather than life-prolonging treatment, more than two-thirds were admitted to intensive care units.25 Most patients and caregivers report wanting to die at home26 and in-home palliative team care is a cost-effective intervention,27 but the value of this form of care is not reflected in many provincial policies. Instead, Canadian families frequently shoulder 25% of the total cost of palliative care because they must pay for home-based services,28 such as nursing and personal care services, that are not provided by governments.
With the goal of improving the congruence between patient treatment preferences for end-of-life care and the services provided, Health Quality Ontario developed an evidentiary platform to inform public policy on strategies to optimize quality end-of-life care in in-patient and outpatient (community) settings. It identified four domains in which access to end-of-life care should be optimized to align with patient preferences: (1) location (determinants of place of death); (2) communication (patient care planning discussions and end-of-life educational interventions); (3) team-based models of care; and (4) services (cardiopulmonary resuscitation [CPR] and supportive interventions for informal caregivers).29
It is well recognized that education in palliative care is lacking in medical school and residency training. In response, the Association of Faculties of Medicine of Canada, in partnership with the Canadian Hospice Palliative Care Association and the Canadian Society of Palliative Care Physicians, conducted the Educating Future Physicians in Palliative and End-of-Life Care Project30 to develop consensus-based competencies for undergraduate medical trainees and a core curriculum that was implemented in all 17 Canadian medical schools. Despite these efforts, a survey conducted by the Canadian Society of Palliative Care Physicians found that the competencies are not being consistently taught in medical schools, as evidenced by the fact that 10 medical schools offered less than 10 hours of teaching on palliative care and two offered none.31
Moreover, evidence suggests that Canadian physicians are not consistently or adequately trained in palliative care. There is a general lack of providers trained in palliative care for service provision, teaching, consultative support to other physicians and research. To fill the observed gap in education, the Royal College of Physicians and Surgeons of Canada is developing Palliative Medicine as a subspecialty, and the College of Family Physicians of Canada is developing a Certificate of Added Competence in Palliative Care.
What is more, different levels of palliative care competencies are required for different physicians:
* All physicians require basic skills in palliative care.
* Palliative consultants and physicians who frequently care for patients with chronic illnesses and/or frail seniors require enhanced skills.
* Palliative medicine specialists and palliative medicine educators require expert skills.
More broadly, the undergraduate curricula of all health care disciplines should include instruction in the principles and practices of palliative care, including how to access specialized palliative care consultation and services.
Role of governments
Access to palliative care must be treated with the same consideration as access to all other medical care. Provincial/territorial and federal legislation, however, is vague in this regard and does not recognize access to palliative care as an entitlement. Government funding of community-based hospice palliative care has not increased proportionately to the number of institutionally based palliative care beds that have been cut, leaving a significant gap in the health care system.32 To address this issue, efforts to broaden the availability of and access to palliative care in Canada need to be intensified. It is imperative that governments develop a common palliative care strategy to ensure equitable access to and adequate standards for quality palliative care, including emergency funding for those who are uninsured.
Integrated palliative approach to care: An approach that focuses on quality of life and reduction of suffering as a goal of care. This approach may coexist with other goals of care - prevention, cure, management of chronic illness - or be the sole focus of care. The palliative approach integrates palliative care services throughout the treatment of a person with serious life-limiting illness, not just at the very end of life.
Palliative care services: Generally consists of palliative care provided by a multidisciplinary team. The team may include a primary care physician, a palliative care physician, nurses, allied health professionals (as needed), social workers, providers of pastoral care and counselling, bereavement specialists and volunteers. The team members work together in a shared care model.
Shared care model: An approach to care that uses the skills and knowledge of a range of health professionals who share joint responsibility for an individual's care. This model involves monitoring and exchanging patient data and sharing skills and knowledge among disciplines.33
1 Policy Resolution GC99-87 - Access to end-of-life and palliative care services. Ottawa: Canadian Medical Association; 1999. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26).
2Policy Resolution GC14-20 - Palliative care services and expertise. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26).
3Policy Resolution GC13-67 - Palliative Care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26).
4Policy Resolution GC13-66 - Palliative Care Services. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26).
5 Policy Resolution GC13-80 - Collaborative palliative care model. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26).
6Policy Document PD15-02 - Euthanasia And Assisted Death (Update 2014). Ottawa: Canadian Medical Association; 2015. Available: https://www.cma.ca/Assets/assetslibrary/document/en/advocacy/EOL/CMA_Policy_Euthanasia_Assisted%20Death_PD15-02-e.pdf#search=Euthanasia%20and (accessed 2015 Nov 26).
7 Policy Resolution GC06-12 - Access to pediatric palliative care. Ottawa: Canadian Medical Association; 2006. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26).
8Policy Resolution GC14-23 - Delivery of quality palliative end-of-life care throughout Canada. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26).
9Policy Resolution GC13-71 - Training in palliative care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26).
10Policy Document PD10-02 - Funding the continuum of care.Ottawa: Canadian Medical Association; 2010. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26).
11Policy Resolution GC13-70 - Palliative Care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26).
12Policy Resolution GC14-26 - Emergency funding for end-of-life care for uninsured people residing in Canada. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26).
13 OHTAC End-of-Life Collaborative. Health care for people approaching the end of life: an evidentiary framework. Toronto: Health Quality Ontario; 2014. Available: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/eol-evidentiary-framework.
14 Quality End-of-Life Care Coalition of Canada. Blueprint for action 2010 to 2012. Ottawa: Quality End-of-Life Care Coalition of Canada; 2010. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf.
15 Fowler R, Hammer M. End-of-life care in Canada. Clin Invest Med. 2013;36(3):E127-E32.
16 Canadian Society of Palliative Care Physicians. Highlights from the National Palliative Medicine Survey. Surrey (BC): Canadian Society of Palliative Care Physicians, Human Resources Committee; May 2015.
17 Bacon J. The palliative approach: improving care for Canadians with life-limiting illnesses. Ottawa: Canadian Hospice Palliative Care Association; 2012. Available: http://www.hpcintegration.ca/media/38753/TWF-palliative-approach-report-English-final2.pdf.
18 Ontario Health Technology Advisory Committee OCDM Collaborative. Optimizing chronic disease management in the community (outpatient) setting (OCDM): an evidentiary framework. Toronto: Health Quality Ontario; 2013. Available: www.hqontario.ca/Portals/0/Documents/eds/ohtas/compendium-ocdm-130912-en.pdf.
19 Zimmermann C, Swami N, Krzyzanowska M, Hannon B, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721-1730.
20 Klinger CA, Howell D, Marshall D, Zakus D, et al. Resource utilization and cost analyses of home-based palliative care service provision: the Niagara West end-of-life shared-care project. Palliat Med. 2013;27(2):115-122.
21 Temel JS, Greer JA, Muzikansky MA, Gallagher ER, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. NEJM. 2010;363:733-742.
22 Bakitas M, Lyons KD, Hegel MT, Balan S, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302:741-749.
23 Quality End-of-Life Care Coalition of Canada, Canadian Hospice Palliative Care Association. The Way Forward National Framework: a roadmap for an integrated palliative approach to care. Ottawa: Quality End-of-Life Care Coalition of Canada; 2014. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf
24 Quality End-of-Life Coalition of Canada, Canadian Hospice Palliative Care Association. The Way Forward National Framework: a roadmap for the integrated palliative approach to care. Quality End-of-Life Coaltion of Canada; 2014. Available: http://www.hpcintegration.ca/media/60044/TWF-framework-doc-Eng-2015-final-April1.pdf.
25 Cook D, Rocker G. End of life care in Canada: a report from the Canadian Academy of Health Sciences Forum. Clin Invest Med. 2013;36(3):E112-E113.
26 Brazil, K, Howell D, Bedard M, Krueger P, et al. Preferences for place of care and place of death among informal caregivers of the terminally ill. Palliat Med. 2005;19(6):492-499.
27 Pham B, Krahn M. End-of-life care interventions: an economic analysis. Ontario Health Quality Technology Assessment Series. 2014;14(18):1-70. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf.
28 Dumont S, Jacobs P, Fassbender K, Anderson D, et al. Costs associated with resource utilization during the palliative phase of care: a Canadian perspective. Palliat Med. 2009;23(8)708-717.
29 OHTAC End-of-Life Collaborative. Health care for people approaching the end of life: an evidentiary framework. Toronto: Health Quality Ontario; 2014. Available: www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/eol-evidentiary-framework
30 Association of Faculties of Medicine of Canada. Educating future physicians in palliative and end-of-life care. Ottawa: Association of Faculties of Medicine of Canada; 2004. Available: http://220.127.116.11/social-educating-physicians-e.php.
31 Daneault S. Undergraduate training in palliative care in Canada in 2011. Montreal: Soins palliatifs, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal; 2012.
32 Canadian Hospice Palliative Care Association. Fact sheet 2012: hospice palliative care in Canada. Available: http://www.chpca.net/media/330558/Fact_Sheet_HPC_in_Canada%20Spring%202014%20Final.pdf.
33 Moorehead, R. Sharing care between allied health professional and general practitioners. Aust Fam Physician. 1995;24(11).